=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003365859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAKETA THOMAS M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2016
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5023 CAROLINA FOREST BLVD
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29579-3578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-497-5929
-----------------------------------------------------
Fax | 833-449-3251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3439
-----------------------------------------------------
City | NORTH MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29582-0439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-839-4447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 91896
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------