1710986757 NPI number — DR. TEMISAN L ETIKERENTSE MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710986757 NPI number — DR. TEMISAN L ETIKERENTSE MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

ETIKERENTSE

Provider First Name:

TEMISAN

Provider Middle Name:

L

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1710986757

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

783 NAVIGATORS RUN

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

MT. PLEASANT

Provider Business Mailing Address State Name:

SC

Provider Business Mailing Address Postal Code:

29464-2829

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

843-886-6729

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

110 EXECUTIVE PKWY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

MONCKS CORNER

Provider Business Practice Location Address State Name:

SC

Provider Business Practice Location Address Postal Code:

29461-3930

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

843-899-9099

Provider Business Practice Location Address Fax Number:

843-899-9091

Provider Enumeration Date:

07/20/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207R00000X , with the licence number:  20234 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: JB021564 . This is a "JUA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 571134452 . This is a "FEDERAL IN" identifier . This identifiers is of the category "OTHER".
• Identifier: GP3914 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 20 20234 . This is a "STATE REGISTRATION" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 20234 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 202346 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: 562413454 . This is a "SECONDARY TAX ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 562413454 . This is a "FEDERAL IN" identifier . This identifiers is of the category "OTHER".
• Identifier: 75767 . This is a "SC PCF" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 9800859 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: GP3438 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
• Identifier: JB021584 . This is a "JUA" identifier . This identifiers is of the category "OTHER".