Healthcare Provider Details

I. General information

NPI: 1447293121
Provider Name (Legal Business Name): DAVID MACY VIDRINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 LACY ST NW
MARIETTA GA
30060-1112
US

IV. Provider business mailing address

PO BOX 23781
NEW YORK NY
10087-3781
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0368
  • Fax: 678-581-5969
Mailing address:
  • Phone: 770-427-0368
  • Fax: 678-581-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number30117
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number109818
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number226983
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME181268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: