Provider Demographics
NPI:1073536744
Name:DEDONIS, JAMES LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LOUIS
Last Name:DEDONIS
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 1:2835 E HIGHWAY 76 STE 5
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6038
Mailing Address - Country:US
Mailing Address - Phone:843-431-2171
Mailing Address - Fax:843-431-2999
Practice Address - Street 1:2835 E HIGHWAY 76 STE 5
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6038
Practice Address - Country:US
Practice Address - Phone:843-431-2171
Practice Address - Fax:843-431-2999
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20887207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0965Medicaid
SC4633Medicare ID - Type Unspecified
SCGP0965Medicaid