Healthcare Provider Details

I. General information

NPI: 1104823384
Provider Name (Legal Business Name): JOHN WALTER STORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2005
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S WYLIE ST
LANCASTER SC
29720-2353
US

IV. Provider business mailing address

209 S WYLIE ST
LANCASTER SC
29720-2353
US

V. Phone/Fax

Practice location:
  • Phone: 803-285-7400
  • Fax: 803-285-7554
Mailing address:
  • Phone: 803-285-7400
  • Fax: 803-285-7554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number10512
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: