Provider Demographics
NPI:1346206919
Name:JIMISON, RAYMOND ELLSWORTH II (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:ELLSWORTH
Last Name:JIMISON
Suffix:II
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:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29903-4207
Mailing Address - Country:US
Mailing Address - Phone:843-846-1239
Mailing Address - Fax:
Practice Address - Street 1:11 ROBERT SMALLS PKWY
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-4216
Practice Address - Country:US
Practice Address - Phone:843-524-8302
Practice Address - Fax:843-379-5974
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC140732Medicaid
SCT24978Medicare UPIN
SC140732Medicaid
SCT249788180Medicare ID - Type Unspecified