Healthcare Provider Details

I. General information

NPI: 1982137204
Provider Name (Legal Business Name): MATTHEW JOHN KHAYATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHLAND MEDICAL PARK DR STE 110
COLUMBIA SC
29203-6859
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-7961
  • Fax: 803-758-0134
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number88250
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: