Healthcare Provider Details

I. General information

NPI: 1982132510
Provider Name (Legal Business Name): DAREN ALEXANDER FOMIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 N FANT ST
ANDERSON SC
29621-4825
US

IV. Provider business mailing address

1409 N FANT ST
ANDERSON SC
29621-4825
US

V. Phone/Fax

Practice location:
  • Phone: 864-231-8599
  • Fax: 864-231-8073
Mailing address:
  • Phone: 864-231-8599
  • Fax: 864-231-8073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0102205409
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number91371
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number05-44847
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: