Provider Demographics
NPI:1740592237
Name:PETTY, JUSTINE SIEGERS (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:SIEGERS
Last Name:PETTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JUSTINE
Other - Middle Name:MARIE
Other - Last Name:SIEGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063
Mailing Address - Country:US
Mailing Address - Phone:803-781-2123
Mailing Address - Fax:803-749-0183
Practice Address - Street 1:121 LUCY LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7835
Practice Address - Country:US
Practice Address - Phone:803-217-2550
Practice Address - Fax:803-217-2548
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1603152WC0802X
SC1603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC1603OtherOPTOMETRIST LICENSE