Provider Demographics
NPI:1033177563
Name:SPONSELLER, JEFFERY L (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:L
Last Name:SPONSELLER
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 1:3152 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-651-1291
Mailing Address - Fax:706-210-8090
Practice Address - Street 1:3152 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907
Practice Address - Country:US
Practice Address - Phone:706-651-1291
Practice Address - Fax:706-210-8090
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002159152W00000X
SC1425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA519944203BMedicaid
SCDG2159Medicaid
GA202I414691Medicare PIN
GA519944203BMedicaid
SCAA32099101Medicare PIN
SCAA3209Medicare UPIN
SCDG2159Medicaid