Basic Information
| Provider Information | |||||||||
| NPI: | 1609803477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EXTINE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST STE 355 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188126603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2516 BROADMOOR BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712012988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188074746 | ||||||||
| FaxNumber: | 3188126034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 071493 | GA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | DO0000001192 | TN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 307337 | LA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2462750 | 05 | LA | MEDICAID | 200037893 | 01 | TN | RAILROAD MEDICARE | OTHER | TN0139 | 01 | TN | AMERICHOICE TENNCARE | OTHER | 1170140002 | 01 | TN | PALMETTO GBA | OTHER | 373856800 | 01 | TN | OWCP | OTHER | 3139316 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | 3304909 | 05 | TN | MEDICAID | 1120944 | 01 | TN | CIGNA | OTHER |