Provider Demographics
NPI:1447203583
Name:LAW, THEODORE W IV (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:W
Last Name:LAW
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2750 LAUREL ST
Mailing Address - Street 2:103
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2038
Mailing Address - Country:US
Mailing Address - Phone:803-254-5171
Mailing Address - Fax:803-779-7403
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:103
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2038
Practice Address - Country:US
Practice Address - Phone:803-254-5171
Practice Address - Fax:803-779-7403
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-07-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC13507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080013983OtherRAILROAD MEDICARE
SC135071Medicaid
D178986050Medicare ID - Type Unspecified
SC135071Medicaid