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General NPI Number Information
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NPI Number | 1588157291
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Entity Type | Individual
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Provider Name | JESSE MICHAEL WILLINGHAM OD
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Gender | Male
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Dates
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Enumeration Date | 06/08/2018
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 717 OLD TROLLEY RD STE 3
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City | SUMMERVILLE
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State | SC
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Zip | 29485-5287
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Country | US
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Telephone | 843-873-1889
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Fax |
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Provider Business Mailing Address
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Address Line | 1816 SUCCESS ST STE 101
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City | NORTH CHARLESTON
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State | SC
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Zip | 29405-7851
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Country | US
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Telephone | 843-203-0200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TUV008748
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT.2201
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License Number State | SC
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