Provider Demographics
NPI:1043298516
Name:PRICKETT, DALTON SHULER (MD FACS)
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:SHULER
Last Name:PRICKETT
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7329
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1850 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-256-3400
Practice Address - Fax:803-256-2039
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16538208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7530Medicaid
SC165387Medicaid
SC165387Medicaid
SCF26043Medicare UPIN