Basic Information
| Provider Information | |||||||||
| NPI: | 1467498709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUTHIER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1818 HENDERSON ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037824278 | ||||||||
| FaxNumber: | 8037823445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 HIGHWAY 17 N | ||||||||
| Address2: | |||||||||
| City: | SURFSIDE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295756015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432381461 | ||||||||
| FaxNumber: | 8438280622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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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 | 207Q00000X | 15530 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 155307 | 05 | SC | MEDICAID |