Provider Demographics
NPI:1285657908
Name:BOATWRIGHT, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:BOATWRIGHT
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 1:2861 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9172
Mailing Address - Country:US
Mailing Address - Phone:843-725-0064
Mailing Address - Fax:843-569-7885
Practice Address - Street 1:2060 CHARLIE HALL BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5830
Practice Address - Country:US
Practice Address - Phone:843-722-2010
Practice Address - Fax:843-723-3914
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13044207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC180033203OtherRAILROAD MEDICARE
SC130441Medicaid
SC5911Medicare PIN
SC5909Medicare PIN
SCE40115Medicare UPIN
SC180033203OtherRAILROAD MEDICARE
SC5910Medicare PIN