Provider Demographics
NPI:1114979259
Name:JESION, LEO J (DO)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:J
Last Name:JESION
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-5747
Mailing Address - Country:US
Mailing Address - Phone:843-782-2767
Mailing Address - Fax:843-549-6867
Practice Address - Street 1:501 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2787
Practice Address - Country:US
Practice Address - Phone:843-782-2767
Practice Address - Fax:843-549-6867
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC008486Medicaid
SCI07930Medicare UPIN
SC008486Medicaid
SCAA04528580Medicare PIN
P00775864Medicare PIN