Provider Demographics
NPI:1821402405
Name:DOLAN JOHNSON, MARY LILLIAN (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LILLIAN
Last Name:DOLAN JOHNSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LILLIAN
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2403 ALLISON RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5923
Mailing Address - Country:US
Mailing Address - Phone:843-524-1078
Mailing Address - Fax:
Practice Address - Street 1:2403 ALLISON RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5923
Practice Address - Country:US
Practice Address - Phone:843-524-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021066390200000X
SC37676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty