Healthcare Provider Details

I. General information

NPI: 1841976412
Provider Name (Legal Business Name): MAURICIO BASTOS PEREIRA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-8905
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax: 843-792-0720
Mailing address:
  • Phone: 843-792-1414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberAL93116
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberAL93116
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: