Healthcare Provider Details

I. General information

NPI: 1558323543
Provider Name (Legal Business Name): TEMUJIN TOM CHAVEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 PAMPLICO HWY SUITE B-125
FLORENCE SC
29505-6047
US

IV. Provider business mailing address

PO BOX 11271
BELFAST ME
04915-4003
US

V. Phone/Fax

Practice location:
  • Phone: 843-674-6400
  • Fax: 843-674-6410
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0101235352
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberTL34011
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: