Provider Demographics
NPI:1720004823
Name:FITES, TERRI L
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:FITES
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TERRI
Other - Middle Name:L
Other - Last Name:DONALDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2517
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151-2517
Mailing Address - Country:US
Mailing Address - Phone:803-774-5248
Mailing Address - Fax:
Practice Address - Street 1:129 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4949
Practice Address - Country:US
Practice Address - Phone:803-774-5248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39399207Q00000X
SC29269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN048580H9Medicaid
KY64104334Medicaid
BF8372687OtherDEA
KY64104334Medicaid
BF8372687OtherDEA