Provider Demographics
NPI:1326369893
Name:LOFTLEY, AUNDREA EASON (MD)
Entity Type:Individual
Prefix:MRS
First Name:AUNDREA
Middle Name:EASON
Last Name:LOFTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:AUNDREA
Other - Middle Name:SHANAE
Other - Last Name:EASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32659207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC326597Medicaid