Provider Demographics
NPI:1073704920
Name:DENNIS J DOUD MD PA
Entity Type:Organization
Organization Name:DENNIS J DOUD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-227-2822
Mailing Address - Street 1:435 EPTING AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4041
Mailing Address - Country:US
Mailing Address - Phone:864-227-2822
Mailing Address - Fax:864-227-3410
Practice Address - Street 1:435 EPTING AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4041
Practice Address - Country:US
Practice Address - Phone:864-227-2822
Practice Address - Fax:864-227-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9278207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC092786Medicaid
SC2113Medicare PIN
SC092786Medicaid