Provider Demographics
NPI:1639168339
Name:DODGE, TERRY L (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:DODGE
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 1:1 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-9769
Mailing Address - Country:US
Mailing Address - Phone:803-581-3151
Mailing Address - Fax:803-385-3183
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706-9769
Practice Address - Country:US
Practice Address - Phone:803-581-3151
Practice Address - Fax:803-385-3183
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6992207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC069927Medicaid
A9373OtherMEDCOST
B92643Medicare UPIN