Provider Demographics
NPI:1689685901
Name:POWELL, O HENDERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:O
Middle Name:HENDERSON
Last Name:POWELL
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 1:2720 SUNSET BLVD
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4810
Mailing Address - Country:US
Mailing Address - Phone:803-936-7679
Mailing Address - Fax:
Practice Address - Street 1:7033 ST ANDREWS RD STE 305
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1179
Practice Address - Country:US
Practice Address - Phone:803-749-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7488207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC074886Medicaid
SCD907856375Medicare PIN
SCD907856106Medicare PIN