Basic Information
| Provider Information | |||||||||
| NPI: | 1023000858 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEATON | ||||||||
| FirstName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 418283 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022418283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035581544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455800 | ||||||||
| FaxNumber: | 8032540821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 51943 | SC | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 33799 | DC | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 519433 | 05 | SC | MEDICAID |