Healthcare Provider Details

I. General information

NPI: 1285632638
Provider Name (Legal Business Name): THOMAS A PRIVETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 AMBASSADOR CAFFERY PKWY STE 401B
LAFAYETTE LA
70508-7265
US

IV. Provider business mailing address

9330 MEDICAL PLAZA DR
CHARLESTON SC
29406
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-4978
  • Fax: 337-470-4238
Mailing address:
  • Phone: 843-847-3225
  • Fax: 843-847-3247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number23118
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number021911
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: