Provider Demographics
NPI:1689012957
Name:LITSEY, JEDIDIAH COLTER (MD)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:COLTER
Last Name:LITSEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1595 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5529
Practice Address - Country:US
Practice Address - Phone:843-212-8080
Practice Address - Fax:438-212-8081
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC35722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC357223Medicaid
SC357223Medicaid