Provider Demographics
NPI:1376527549
Name:GHERAIBEH, JAFER NASSER (MD)
Entity Type:Individual
Prefix:MR
First Name:JAFER
Middle Name:NASSER
Last Name:GHERAIBEH
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 1:500 THURGOOD MARSHALL HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-4143
Mailing Address - Country:US
Mailing Address - Phone:843-355-1969
Mailing Address - Fax:843-355-1969
Practice Address - Street 1:500 THURGOOD MARSHALL HWY
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-4143
Practice Address - Country:US
Practice Address - Phone:843-355-1969
Practice Address - Fax:843-355-1869
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10718174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC107182Medicaid