Healthcare Provider Details

I. General information

NPI: 1588157291
Provider Name (Legal Business Name): JESSE MICHAEL WILLINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 SUCCESS ST STE 101
NORTH CHARLESTON SC
29405-7851
US

IV. Provider business mailing address

1816 SUCCESS ST STE 101
NORTH CHARLESTON SC
29405-7851
US

V. Phone/Fax

Practice location:
  • Phone: 843-203-0200
  • Fax:
Mailing address:
  • Phone: 843-203-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV008748
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.2201
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: