Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 82277 | SC |
NPI | 1003158908 |
---|---|
Provider Name | Mark Deford |
First Address | Daniel Island, SC 29492-8905 |
Second Address | North Charleston, SC 29406-9164 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2013 |
Last Update Date | 06/05/2019 |