Provider Demographics
NPI:1710986757
Name:ETIKERENTSE, TEMISAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:TEMISAN
Middle Name:L
Last Name:ETIKERENTSE
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 1:783 NAVIGATORS RUN
Mailing Address - Street 2:
Mailing Address - City:MT. PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-2829
Mailing Address - Country:US
Mailing Address - Phone:843-886-6729
Mailing Address - Fax:
Practice Address - Street 1:110 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3930
Practice Address - Country:US
Practice Address - Phone:843-899-9099
Practice Address - Fax:843-899-9091
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20234207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCJB021564OtherJUA
571134452OtherFEDERAL IN
SCGP3914Medicaid
SC20 20234OtherSTATE REGISTRATION
SC20234OtherMEDICAL LICENSE
SC202346Medicaid
SC562413454OtherSECONDARY TAX ID
562413454OtherFEDERAL IN
SC75767OtherSC PCF
NC9800859OtherMEDICAL LICENSE
SCGP3438Medicaid
JB021584OtherJUA
JB021584OtherJUA
SCG78837285Medicare UPIN
SCGP3438Medicaid
SCGP3914Medicaid