Provider Demographics
NPI:1205065539
Name:POURNARAS, DANA BETTINA (MD)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:BETTINA
Last Name:POURNARAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:BETTINA
Other - Last Name:POLYDOROPOULOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4615 OLEANDER DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5741
Mailing Address - Country:US
Mailing Address - Phone:843-497-5929
Mailing Address - Fax:843-839-4448
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:843-839-4448
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL35193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL35193OtherSTATE LICENSE
SC351933Medicaid
SCAA97285373Medicare UPIN