Provider Demographics
NPI:1780162446
Name:JESSURUN, DEBORAH (OD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:JESSURUN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1031 GRANDIFLORA DR
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7453
Practice Address - Country:US
Practice Address - Phone:910-371-0540
Practice Address - Fax:910-371-2463
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2606152W00000X
FLOPFC90152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist