Healthcare Provider Details

I. General information

NPI: 1205805215
Provider Name (Legal Business Name): CHARLES DAVID PETIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 FARROW RD SUITE 300
COLUMBIA SC
29203-7607
US

IV. Provider business mailing address

PO BOX 402145
ATLANTA GA
30384-2145
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-1210
  • Fax: 803-434-1212
Mailing address:
  • Phone: 803-296-7305
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number13746
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: