Provider Demographics
NPI:1861438699
Name:DANTZLER, BRIAN SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SAMUEL
Last Name:DANTZLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2115
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-2115
Mailing Address - Country:US
Mailing Address - Phone:828-575-2644
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:46 MARKFIELD DR
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6982
Practice Address - Country:US
Practice Address - Phone:843-556-7048
Practice Address - Fax:843-556-2938
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007053207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC070531OtherUNITED HEALTH CARE
SC070531Medicaid
SC189320OtherMEDCOST
SCB922437953OtherMEDICARE PTAN
SCB922435238OtherMEDICARE PTAN
SCB922435238OtherMEDICARE PTAN
SCB92243Medicare UPIN