Provider Demographics
NPI:1922044429
Name:NETHERCUTT, LLOYD W JR (OD)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:W
Last Name:NETHERCUTT
Suffix:JR
Gender:M
Credentials:OD
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 5721
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29250
Mailing Address - Country:US
Mailing Address - Phone:803-779-2273
Mailing Address - Fax:803-799-0854
Practice Address - Street 1:701 BULTMAN DRIVE
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150
Practice Address - Country:US
Practice Address - Phone:803-773-4723
Practice Address - Fax:803-775-5211
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20005987OtherSELECT HEALTH OF SC
SCD06152Medicaid
SC20005987OtherSELECT HEALTH OF SC