Provider Demographics
NPI:1568451466
Name:PITTARD, JOHN CAMERON (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:CAMERON
Last Name:PITTARD
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 1:255 WARLEY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4444
Mailing Address - Country:US
Mailing Address - Phone:843-669-6694
Mailing Address - Fax:843-669-2500
Practice Address - Street 1:255 WARLEY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4444
Practice Address - Country:US
Practice Address - Phone:843-669-6694
Practice Address - Fax:843-669-2500
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12125207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC121255Medicaid
B92265Medicare UPIN
SC121255Medicaid