Provider Demographics
NPI:1942267216
Name:SHILLITO, JUDY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:A
Last Name:SHILLITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2647
Mailing Address - Country:US
Mailing Address - Phone:803-758-2600
Mailing Address - Fax:
Practice Address - Street 1:631 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3030
Practice Address - Country:US
Practice Address - Phone:843-881-0815
Practice Address - Fax:843-881-0743
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC135277Medicaid
F94519Medicare UPIN