Provider Demographics
NPI:1578686598
Name:DRISCOLL, JOSEPH J (OD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:J
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S Y SQ
Mailing Address - Street 2:P.O. BOX 269
Mailing Address - City:SELMER
Mailing Address - State:TN
Mailing Address - Zip Code:38375-1739
Mailing Address - Country:US
Mailing Address - Phone:731-645-5236
Mailing Address - Fax:
Practice Address - Street 1:135 S Y SQ
Practice Address - Street 2:
Practice Address - City:SELMER
Practice Address - State:TN
Practice Address - Zip Code:38375-1739
Practice Address - Country:US
Practice Address - Phone:731-645-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN570152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3593361Medicaid
TN2007177OtherBLUE CROSS BLUE SHIELD TN
TN2007177OtherBLUE CROSS BLUE SHIELD TN
TN3593361Medicare PIN