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General NPI Number Information
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NPI Number | 1982691796
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Entity Type | Individual
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Provider Name | VANESSA K WIDEMAN MD
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Gender | Female
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Dates
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Enumeration Date | 10/06/2005
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Last Update Date | 12/17/2024
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Provider Practice Location Address
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Address Line | 1325 S CAROLINA RD STE 11
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City | EASTOVER
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State | SC
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Zip | 29044
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Country | US
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Telephone | 803-647-8295
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Fax | 803-647-8612
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Provider Business Mailing Address
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Address Line | 1325 S CAROLINA RD STE 11
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City | EASTOVER
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State | SC
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Zip | 29044-5000
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Country | US
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Telephone | 803-647-8295
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Fax | 803-647-8612
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 29480
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License Number State | SC
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