MEDICARE: DEVANAND ANTHONY DOMINIQUE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician	61330	SC
2	207T00000X	Neurological Surgery Physician	MD420830	PA

General Provider Information

NPI Number	:	1477541456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVANAND ANTHONY DOMINIQUE MD

Provider Business Mailing Address
First Line	:	300 E MCBEE AVE FL 4
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-2842
Country	:	US
Telephone Number	:	864-522-8603
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 RICHLAND MEDICAL PARK DR STE 310
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6862
Country	:	US
Telephone Number	:	803-434-8323
Fax Number	:	803-434-8326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	09/08/2023

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