Provider Demographics
NPI:1720196777
Name:HEADDEN, GARY FLETCHER (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:FLETCHER
Last Name:HEADDEN
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 1:1341 COLLEGE PARK RD
Mailing Address - Street 2:STE A
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8635
Mailing Address - Country:US
Mailing Address - Phone:843-400-0028
Mailing Address - Fax:843-790-8449
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15574207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC155744Medicaid
SC155744Medicaid
F74775Medicare UPIN
SCF74775Medicare ID - Type Unspecified