Basic Information
| Provider Information | |||||||||
| NPI: | 1942260187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGLESTON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | DU BOSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13955 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294223955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437955362 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 418 FOLLY RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437955362 | ||||||||
| FaxNumber: | 8437951921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | 7056 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP6738 | 05 | SC | MEDICAID | 070568 | 05 | SC | MEDICAID | P00247623 | 01 | SC | RAILROAD MEDICARE | OTHER | 202583825 | 01 | SC | BCBS ID NUMBER | OTHER |