Provider Demographics
NPI: | 1710921689 |
---|---|
Name: | JESTER, DAVID M (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DAVID |
Middle Name: | M |
Last Name: | JESTER |
Suffix: | |
Gender: | M |
Credentials: | MD |
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 2510 |
Mailing Address - Street 2: | |
Mailing Address - City: | EVANS |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30809-2510 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 706-922-8274 |
Mailing Address - Fax: | 706-922-6695 |
Practice Address - Street 1: | 105 EAST HUGH STREET |
Practice Address - Street 2: | |
Practice Address - City: | NORTH AUGUSTA |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29841 |
Practice Address - Country: | US |
Practice Address - Phone: | 803-279-6800 |
Practice Address - Fax: | 803-279-2876 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-15 |
Last Update Date: | 2024-03-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 040111 | 207Q00000X |
SC | 27787 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | 10056128 | Other | AMERIGROUP |
SC | G40111 | Medicaid | |
GA | 000660206B | Medicaid | |
SC | 27787 | Other | SC STATE MEDICAL BOARD LICENSE |
SC | 040111 | Other | LICENSE |
SC | BJ4604054 | Other | DEA |
SC | G40111 | Medicaid |