Healthcare Provider Details

I. General information

NPI: 1750637633
Provider Name (Legal Business Name): IOANNIS M LIVADITIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 ROBERTS ST
CAMDEN SC
29020-3737
US

IV. Provider business mailing address

3533 S ALAMEDA ST
CORPUS CHRISTI TX
78411-1721
US

V. Phone/Fax

Practice location:
  • Phone: 803-432-4311
  • Fax: 803-438-4391
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number39388
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39388
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: