Provider Demographics
NPI:1679914212
Name:WIGINGTON, KELTON BANKS (MD)
Entity Type:Individual
Prefix:
First Name:KELTON
Middle Name:BANKS
Last Name:WIGINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 SUNSET
Mailing Address - Street 2:INTERNAL MEDICINE CLINIC
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-4197
Mailing Address - Fax:803-434-4160
Practice Address - Street 1:1801 SUNSET
Practice Address - Street 2:INTERNAL MEDICINE CLINIC
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-4197
Practice Address - Fax:803-434-4160
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL36094207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine