Provider Demographics
NPI:1174551253
Name:SUBER, DEALVA TAUNDOLYN (MD)
Entity type:Individual
Prefix:DR
First Name:DEALVA
Middle Name:TAUNDOLYN
Last Name:SUBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DEALVA
Other - Middle Name:TAUNDOLYN
Other - Last Name:SUBER-MITCHELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:803-695-8062
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:803-695-8062
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15386207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC153862Medicaid
SC153862Medicaid
SCE897070281Medicare PIN