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: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 EXCHANGE DR
LUGOFF SC
29078-9198
US

IV. Provider business mailing address

PO BOX 520
LUGOFF SC
29078-0520
US

V. Phone/Fax

Practice location:
  • Phone: 803-408-3277
  • Fax: 803-408-3282
Mailing address:
  • Phone: 803-408-3277
  • Fax: 803-408-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number226983
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number30117
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: