Provider Demographics
NPI:1104310671
Name:DATAR, NACHIKET NITIN
Entity type:Individual
Prefix:
First Name:NACHIKET
Middle Name:NITIN
Last Name:DATAR
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 1:809 82ND PARKWAY GRAND STRAND MEDICAL CENTER/
Mailing Address - Street 2:GME OFFICE
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:843-848-4679
Mailing Address - Fax:843-848-4682
Practice Address - Street 1:809 82ND PARKWAY GRAND STRAND MEDICAL CENTER/
Practice Address - Street 2:GME OFFICE
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572
Practice Address - Country:US
Practice Address - Phone:843-848-4679
Practice Address - Fax:843-848-4682
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2021-11-04
Deactivation Date:2019-01-25
Deactivation Code:
Reactivation Date:2019-03-11
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021030733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program