Provider Demographics
NPI:1073617122
Name:DETORRE, JAMES B (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:B
Last Name:DETORRE
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 1:109 BEE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-5703
Mailing Address - Country:US
Mailing Address - Phone:843-789-7330
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-5703
Practice Address - Country:US
Practice Address - Phone:843-789-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23690207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11054Medicaid
SC11054Medicaid
SC11054Medicaid