Provider Demographics
NPI:1770338568
Name:WILLAFORD, JAMES DEWAYNE (LDO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DEWAYNE
Last Name:WILLAFORD
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9126 MOULTRIE HWY
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-4533
Mailing Address - Country:US
Mailing Address - Phone:229-590-8680
Mailing Address - Fax:
Practice Address - Street 1:3274 INNER PERIMETER RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1073
Practice Address - Country:US
Practice Address - Phone:229-590-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6077156FX1800X
GA1550156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician