Basic Information
| Provider Information | |||||||||
| NPI: | 1750499604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETAR | ||||||||
| FirstName: | DEWEY | ||||||||
| MiddleName: | TODD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743070 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645604304 | ||||||||
| FaxNumber: | 8645604413 | ||||||||
| Practice Location | |||||||||
| Address1: | 1595 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294835529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432128080 | ||||||||
| FaxNumber: | 8437891521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2020-00089 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 483 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004836 | 05 | SC | MEDICAID | SC14336067 | 01 | SC | MEDICARE PIN | OTHER | SC14336084 | 01 | SC | MEDICARE PIN | OTHER | SC1433J577 | 01 | SC | MEDICARE PIN | OTHER |