Provider Demographics
NPI:1649475740
Name:DR. TIM JESSEE, OPTOMETRY INC
Entity type:Organization
Organization Name:DR. TIM JESSEE, OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:GARLAND
Authorized Official - Last Name:JESSEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:540-375-3937
Mailing Address - Street 1:1851 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3111
Mailing Address - Country:US
Mailing Address - Phone:540-375-3937
Mailing Address - Fax:540-387-4219
Practice Address - Street 1:1851 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3111
Practice Address - Country:US
Practice Address - Phone:540-375-3937
Practice Address - Fax:540-387-4219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000391152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010237581Medicaid
VA186600OtherANTHEM BCBS
VA010237581Medicaid
VA186600OtherANTHEM BCBS
VA00W980D01Medicare ID - Type Unspecified