Healthcare Provider Details

I. General information

NPI: 1427057009
Provider Name (Legal Business Name): DANIEL P BOUKNIGHT MD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DANIEL PINCKNEY BOUKNIGHT MD

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WELLNESS BLVD STE 106
IRMO SC
29063-2872
US

IV. Provider business mailing address

1 WELLNESS BLVD STE 106
IRMO SC
29063-2872
US

V. Phone/Fax

Practice location:
  • Phone: 803-888-2282
  • Fax: 803-888-2299
Mailing address:
  • Phone: 803-888-2282
  • Fax: 803-888-2299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number17456
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number17456
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: