Provider Demographics
NPI:1831452853
Name:SUMTER, DEZMOND BERNARD
Entity type:Individual
Prefix:
First Name:DEZMOND
Middle Name:BERNARD
Last Name:SUMTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:3209 COLONIAL DR.
Practice Address - Street 2:FAM MED -
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6116
Practice Address - Fax:803-434-8478
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34934207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC349340Medicaid
SCSC95122353Medicare PIN
SCSC9512F935Medicare PIN