Healthcare Provider Details

I. General information

NPI: 1891770962
Provider Name (Legal Business Name): JOSEPH M LALLY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 DOUGHTY ST STE 330
CHARLESTON SC
29403-5736
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 843-722-7705
  • Fax: 843-722-7149
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number16001
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: