Basic Information
| Provider Information | |||||||||
| NPI: | 1457384935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALAL | ||||||||
| FirstName: | MAYANK | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 FARROW RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292033220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435444098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1035 CHERAW ST. | ||||||||
| Address2: | |||||||||
| City: | BENNETTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435444098 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 06/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD21346 | SC | N | Other Service Providers | Specialist | 2084P0800X | 21346 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084F0202X | 21346 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0804X | 21346 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 213469 | 05 | SC | MEDICAID |