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General NPI Number Information
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NPI Number | 1750499604
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Entity Type | Individual
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Provider Name | DEWEY TODD DETAR DO
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Gender | Male
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 06/09/2021
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Provider Practice Location Address
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Address Line | 1595 CENTRAL AVE
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City | SUMMERVILLE
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State | SC
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Zip | 29483-5529
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Country | US
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Telephone | 843-212-8080
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Fax | 843-789-1521
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Provider Business Mailing Address
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Address Line | PO BOX 743070
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City | ATLANTA
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State | GA
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Zip | 30374-3070
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Country | US
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Telephone | 864-560-4304
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Fax | 864-560-4413
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2020-00089
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 483
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License Number State | SC
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