Provider Demographics
NPI:1023679396
Name:DEECONDA, ANURAG (MD)
Entity type:Individual
Prefix:
First Name:ANURAG
Middle Name:
Last Name:DEECONDA
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 1:35 FOLLY ROAD BLVD UNIT 116
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7588
Mailing Address - Country:US
Mailing Address - Phone:803-318-7604
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE RM 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8905
Practice Address - Country:US
Practice Address - Phone:803-318-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82952207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine