Provider Demographics
NPI:1619491529
Name:HAM, BRIAN DEMETRIUS (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DEMETRIUS
Last Name:HAM
Suffix:
Gender:M
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4216
Mailing Address - Country:US
Mailing Address - Phone:843-309-9754
Mailing Address - Fax:
Practice Address - Street 1:114 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4216
Practice Address - Country:US
Practice Address - Phone:843-309-9754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management