Provider Demographics
NPI:1467498709
Name:GAUTHIER, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:GAUTHIER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-782-4278
Mailing Address - Fax:803-782-3445
Practice Address - Street 1:1600 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6015
Practice Address - Country:US
Practice Address - Phone:843-238-1461
Practice Address - Fax:843-828-0622
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC15530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC155307Medicaid
E60392Medicare UPIN