Provider Demographics
NPI:1972504645
Name:JESSUP, NEAL S (OD)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:S
Last Name:JESSUP
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-0488
Mailing Address - Country:US
Mailing Address - Phone:540-343-2197
Mailing Address - Fax:540-343-3575
Practice Address - Street 1:2205 ORANGE AVE NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-8305
Practice Address - Country:US
Practice Address - Phone:540-343-2197
Practice Address - Fax:540-343-3575
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601001553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010220131Medicaid
VA5799990001Medicare NSC
VA00W506D01Medicare PIN
VAT-83203Medicare UPIN
VAP00242042Medicare PIN