Healthcare Provider Details

I. General information

NPI: 1831452853
Provider Name (Legal Business Name): DEZMOND BERNARD SUMTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 COLONIAL DR. FAM MED -
COLUMBIA SC
29203
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-6116
  • Fax: 803-434-8478
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number34934
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: