Healthcare Provider Details

I. General information

NPI: 1538125315
Provider Name (Legal Business Name): SHERRY JANE FAMORCA VIDUYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SPRINGHALL DR STE A
GOOSE CREEK SC
29445-5335
US

IV. Provider business mailing address

PO BOX 13955
CHARLESTON SC
29422-3955
US

V. Phone/Fax

Practice location:
  • Phone: 843-973-8503
  • Fax: 843-990-5068
Mailing address:
  • Phone: 843-779-6444
  • Fax: 843-779-6438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19583
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: