Provider Demographics
NPI:1750499604
Name:DETAR, DEWEY TODD (DO)
Entity Type:Individual
Prefix:DR
First Name:DEWEY
Middle Name:TODD
Last Name:DETAR
Suffix:
Gender:M
Credentials:DO
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1595 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-5529
Practice Address - Country:US
Practice Address - Phone:843-212-8080
Practice Address - Fax:843-789-1521
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00089207Q00000X
SC483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC004836Medicaid
SCSC14336067OtherMEDICARE PIN
SCSC14336084OtherMEDICARE PIN
SCSC1433J577OtherMEDICARE PIN