Provider Demographics
NPI:1891751764
Name:BOZEMAN, ELIZABETH WAGNER (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WAGNER
Last Name:BOZEMAN
Suffix:
Gender:
Credentials:MD
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 601743
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1743
Mailing Address - Country:US
Mailing Address - Phone:843-777-7555
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:800 E CHEVES ST STE 350
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2649
Practice Address - Country:US
Practice Address - Phone:843-777-7555
Practice Address - Fax:843-777-7563
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272604208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL4813Medicaid
SCTL4813Medicaid
SCE479424300Medicare PIN
SCE479424300Medicare ID - Type Unspecified