Provider Demographics
NPI:1710941802
Name:FANT, JOHN ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALEXANDER
Last Name:FANT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:234 WATERFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-9067
Mailing Address - Country:US
Mailing Address - Phone:803-536-5122
Mailing Address - Fax:864-223-1396
Practice Address - Street 1:3000 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-1442
Practice Address - Country:US
Practice Address - Phone:864-223-3070
Practice Address - Fax:864-223-1396
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17118207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC171183Medicaid
F891997134Medicare PIN
F89199Medicare UPIN
SC220031272Medicare PIN