Provider Demographics
NPI:1073521662
Name:GARRETT, BERTRAM DODSON (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:DODSON
Last Name:GARRETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 KNIGHT LANE BLDG H
Mailing Address - Street 2:BUREAU OF MED & SURG, ATTN MEDICAL STAFF SERVICES
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:843-422-1033
Mailing Address - Fax:
Practice Address - Street 1:10 FORT LYTTLETON
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906
Practice Address - Country:US
Practice Address - Phone:843-422-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD32514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM66228735Medicaid
NM66228735Medicaid
SCAA50245773Medicare PIN
NM342417702Medicare ID - Type Unspecified
SCAA50249192Medicare PIN