Provider Demographics
NPI:1538145438
Name:DUBOSE, E MACDONALD (MD)
Entity Type:Individual
Prefix:
First Name:E
Middle Name:MACDONALD
Last Name:DUBOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:MACDONALD
Other - Last Name:DUBOSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:240 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4256
Mailing Address - Country:US
Mailing Address - Phone:803-773-4411
Mailing Address - Fax:803-774-2204
Practice Address - Street 1:240 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4256
Practice Address - Country:US
Practice Address - Phone:803-773-4411
Practice Address - Fax:803-774-2204
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC073440Medicaid
570650695OtherEIN
570650695OtherEIN
SC073440Medicaid