Provider Demographics
NPI:1942294004
Name:DETERS, ROBERT L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:DETERS
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 EAST MEDICAL LANE
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4801
Practice Address - Country:US
Practice Address - Phone:803-935-8410
Practice Address - Fax:803-936-7816
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78809208100000X, 2081P2900X
NH115262081P2900X
SC81664208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
M20928OtherMEDICARE GROUP
MA3118916Medicaid
MA110053869AMedicaid
NH30201961Medicaid
NH80667OtherCIGNA
NH30201961Medicaid
RE6543Medicare PIN
NH80667OtherCIGNA