Provider Demographics
NPI:1336114834
Name:WITHERSPOON, PATRICIA WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:WILSON
Last Name:WITHERSPOON
Suffix:
Gender:F
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3209 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6930
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-434-7231
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC172128Medicaid
SC172128Medicaid
SCG153152353Medicare PIN
G153152353Medicare ID - Type Unspecified