Basic Information
Provider Information | |||||||||
NPI: | 1861438699 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANTZLER | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | SAMUEL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2115 | ||||||||
Address2: |   | ||||||||
City: | SKYLAND | ||||||||
State: | NC | ||||||||
PostalCode: | 287762115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8285752644 | ||||||||
FaxNumber: | 8283502174 | ||||||||
Practice Location | |||||||||
Address1: | 46 MARKFIELD DR | ||||||||
Address2: | SUITE A | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294076982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435567048 | ||||||||
FaxNumber: | 8435562938 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2006 | ||||||||
LastUpdateDate: | 11/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 007053 | SC | Y |   | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | 070531 | 01 | SC | UNITED HEALTH CARE | OTHER | 070531 | 05 | SC |   | MEDICAID | 189320 | 01 | SC | MEDCOST | OTHER | B922437953 | 01 | SC | MEDICARE PTAN | OTHER | B922435238 | 01 | SC | MEDICARE PTAN | OTHER |