Healthcare Provider Details

I. General information

NPI: 1063687325
Provider Name (Legal Business Name): DAVID WATSON RODWELL III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 11/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 BROAD ST SUITE 200
CHARLESTON SC
29401-2936
US

IV. Provider business mailing address

67 BROAD ST SUITE 200
CHARLESTON SC
29401-2936
US

V. Phone/Fax

Practice location:
  • Phone: 843-628-1415
  • Fax:
Mailing address:
  • Phone: 843-628-1415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberMD.206139
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMD.206139
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: