Healthcare Provider Details

I. General information

NPI: 1811292055
Provider Name (Legal Business Name): DEEWAN DEEWAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 BERNARDIN AVE STE 200
COLUMBIA SC
29204-2044
US

IV. Provider business mailing address

1655 BERNARDIN AVE STE 200
COLUMBIA SC
29204-2044
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-1137
  • Fax: 803-256-1138
Mailing address:
  • Phone: 803-256-1137
  • Fax: 803-256-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40554
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number40554
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: