Provider Demographics
NPI:1770036410
Name:ANTONOVICH, DEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DEVIN
Middle Name:
Last Name:ANTONOVICH
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 1:9267 MEDICAL PLAZA DR STE G
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9139
Mailing Address - Country:US
Mailing Address - Phone:843-797-3636
Mailing Address - Fax:
Practice Address - Street 1:176 MCSWAIN DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4825
Practice Address - Country:US
Practice Address - Phone:843-797-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-29
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39925207LP2900X
SCMMD.39925.LL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC399251Medicaid