Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YP0228X | Pediatric Otolaryngology | 226983 | MA |
Y | 207YP0228X | Pediatric Otolaryngology | 30117 | SC |
NPI | 1447293121 |
---|---|
Provider Name | Dr. David Macy Vidrine |
First Address | Lugoff, SC 29078-0520 |
Second Address | Lugoff, SC 29078-9198 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2006 |
Last Update Date | 26/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
301177 | (05) | SC |
DE5192 | UNSPECIFIED (01) | SC |
H88895 | (02) | SC |