Provider Demographics
NPI:1740298876
Name:GADDY, MCKETHAN R (OD)
Entity type:Individual
Prefix:DR
First Name:MCKETHAN
Middle Name:R
Last Name:GADDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2560
Mailing Address - Country:US
Mailing Address - Phone:843-774-2020
Mailing Address - Fax:843-774-3391
Practice Address - Street 1:300 E MONROE ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-2560
Practice Address - Country:US
Practice Address - Phone:843-774-2020
Practice Address - Fax:843-774-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC631152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDO6312Medicaid
0287930001Medicare NSC
SCT24790Medicare UPIN