Provider Demographics
NPI:1477640647
Name:GOLTRA, DAVID DWIGHT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DWIGHT
Last Name:GOLTRA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:582 LONE TREE DRIVE
Mailing Address - Street 2:582 LONG POINT ROAD
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-0523
Mailing Address - Country:US
Mailing Address - Phone:843-352-0674
Mailing Address - Fax:843-971-8832
Practice Address - Street 1:582 LONE TREE DRIVE
Practice Address - Street 2:582 LONG POINT RD
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-352-0674
Practice Address - Fax:843-971-8832
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC147642085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC147647Medicaid
SC147647Medicaid
SCA15601Medicare ID - Type UnspecifiedMEDICARE OF SC