Provider Demographics
NPI:1013993583
Name:CONSTABLE, DEANNA L (MD)
Entity Type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:L
Last Name:CONSTABLE
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 1:105 OFFICE PARK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5959
Mailing Address - Country:US
Mailing Address - Phone:803-699-5540
Mailing Address - Fax:803-699-5547
Practice Address - Street 1:105 OFFICE PARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5959
Practice Address - Country:US
Practice Address - Phone:803-699-5540
Practice Address - Fax:803-699-5547
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14493174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC144935Medicaid
SCF700967807Medicare PIN
SC144935Medicaid