Provider Demographics
NPI:1134417694
Name:DEAN, ASHLEY JAE (MD)
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:JAE
Last Name:DEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHLEY
Other - Middle Name:JAE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:1316 N LAKE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7653
Practice Address - Country:US
Practice Address - Phone:803-358-1191
Practice Address - Fax:803-358-1180
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL33685207Q00000X
IAMD-45827207Q00000X
SC33685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC336853Medicaid
SCSC4006A871Medicare PIN
SCSC4006E479Medicare PIN