Healthcare Provider Details

I. General information

NPI: 1366941148
Provider Name (Legal Business Name): DJB MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 FAIRCHILD ST STE 170
DANIEL ISLAND SC
29492-7602
US

IV. Provider business mailing address

115 FAIRCHILD ST STE 170
DANIEL ISLAND SC
29492-7602
US

V. Phone/Fax

Practice location:
  • Phone: 803-339-1563
  • Fax: 803-746-7902
Mailing address:
  • Phone: 803-339-1563
  • Fax: 803-746-7902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANIEL J. BALOG
Title or Position: DIRECTOR
Credential: MD
Phone: 803-339-1563