Healthcare Provider Details

I. General information

NPI: 1528012960
Provider Name (Legal Business Name): LISA S HUTTO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STE 430 9 RICHLAND MEDICAL PK
COLUMBIA SC
29203-6870
US

IV. Provider business mailing address

STE 430 9 RICHLAND MEDICAL PK
COLUMBIA SC
29203-6870
US

V. Phone/Fax

Practice location:
  • Phone: 803-765-9435
  • Fax: 803-765-2446
Mailing address:
  • Phone: 803-765-9435
  • Fax: 803-765-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number12987
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: