Healthcare Provider Details

I. General information

NPI: 1568826030
Provider Name (Legal Business Name): LUKE BIDIKOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BRETTWOOD TRCE
CLYDE NC
28721-8021
US

IV. Provider business mailing address

15 BRETTWOOD TRCE
CLYDE NC
28721-8021
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-9700
  • Fax: 828-452-3701
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2021-01597
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2021-01597
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: