Provider Demographics
NPI:1861492407
Name:JERGE, LARRY F (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:F
Last Name:JERGE
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 1:600 PINE LINKS DR
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-7205
Mailing Address - Country:US
Mailing Address - Phone:803-325-4298
Mailing Address - Fax:
Practice Address - Street 1:1151 STONECREST BLVD.
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-802-4733
Practice Address - Fax:803-802-4735
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUT-003877-1152W00000X
SC1468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD14688Medicaid
SCAA25036691Medicare PIN
SCAA25035531Medicare PIN
SC11730BMedicare PIN
SCD14688Medicaid
SCAA25036690Medicare PIN