Provider Demographics
NPI:1952416257
Name:KERRISON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KERRISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 MARY ADER AVE
Mailing Address - Street 2:BLDG D
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5896
Mailing Address - Country:US
Mailing Address - Phone:843-763-4466
Mailing Address - Fax:843-614-4285
Practice Address - Street 1:3531 MARY ADER AVE
Practice Address - Street 2:BLDG D
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5896
Practice Address - Country:US
Practice Address - Phone:843-763-4466
Practice Address - Fax:843-614-4285
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC28305207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC283053Medicaid
SC283053Medicaid