Healthcare Provider Details

I. General information

NPI: 1922034123
Provider Name (Legal Business Name): RUBINA WADUD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 48TH AVE N STE B
MYRTLE BEACH SC
29577
US

IV. Provider business mailing address

1301 48TH AVE N STE B
MYRTLE BEACH SC
29577-5427
US

V. Phone/Fax

Practice location:
  • Phone: 843-497-1441
  • Fax: 843-497-3003
Mailing address:
  • Phone: 843-293-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberSC21095
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier210952
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: