Healthcare Provider Details

I. General information

NPI: 1336522648
Provider Name (Legal Business Name): TIFFANY VINSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 HIGHWAY 17 N
SURFSIDE BEACH SC
29575
US

IV. Provider business mailing address

1600 HIGHWAY 17 N
SURFSIDE BEACH SC
29575-6015
US

V. Phone/Fax

Practice location:
  • Phone: 843-238-1461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301108149
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD81605
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: