Basic Information
| Provider Information | |||||||||
| NPI: | 1710921689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESTER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1967 | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308091967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069228251 | ||||||||
| FaxNumber: | 7069226695 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 EAST HUGH STREET | ||||||||
| Address2: | |||||||||
| City: | NORTH AUGUSTA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032796800 | ||||||||
| FaxNumber: | 8032792876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27787 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 040111 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000660206B | 05 | GA | MEDICAID | 10056128 | 01 | GA | AMERIGROUP | OTHER | G40111 | 05 | SC | MEDICAID | 27787 | 01 | SC | SC STATE MEDICAL BOARD LICENSE | OTHER |