Provider Demographics
NPI:1639163058
Name:RILEY, EUSTACE DAVID IV (MD)
Entity Type:Individual
Prefix:DR
First Name:EUSTACE
Middle Name:DAVID
Last Name:RILEY
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3410 COKESBURY RD
Mailing Address - Street 2:
Mailing Address - City:HODGES
Mailing Address - State:SC
Mailing Address - Zip Code:29653-9181
Mailing Address - Country:US
Mailing Address - Phone:864-227-2099
Mailing Address - Fax:864-227-1779
Practice Address - Street 1:3410 COKESBURY RD
Practice Address - Street 2:
Practice Address - City:HODGES
Practice Address - State:SC
Practice Address - Zip Code:29653-9181
Practice Address - Country:US
Practice Address - Phone:864-227-2099
Practice Address - Fax:864-227-1779
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC16253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL13901Medicaid
SCL13901Medicaid