Provider Demographics
NPI:1740235563
Name:JETTON, ROBERT L (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:JETTON
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:PO BOX 17527
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29606-8527
Mailing Address - Country:US
Mailing Address - Phone:864-242-5872
Mailing Address - Fax:864-242-5640
Practice Address - Street 1:369 WOODRUFF RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3415
Practice Address - Country:US
Practice Address - Phone:864-242-5872
Practice Address - Fax:864-242-5640
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6655207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC066555Medicaid
B92540Medicare UPIN
SC066555Medicaid