Healthcare Provider Details

I. General information

NPI: 1699742825
Provider Name (Legal Business Name): JAMES WILKS FANT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MEDICAL PARK RD SUITE 501
COLUMBIA SC
29203-6808
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-3320
  • Fax: 803-540-1111
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17608
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number17608
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: