MEDICARE: LYDIA IVETTE VIDAL-CARDOZO PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	C0000746	MD
2	363AM0700X	Medical Physician Assistant	PA1294	SC

General Provider Information

NPI Number	:	1174533863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA IVETTE VIDAL-CARDOZO PAC

Provider Business Mailing Address
First Line	:	108 FINNEGAN CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-4205
Country	:	US
Telephone Number	:	843-909-9993
Fax Number	:	843-903-3366

Provider Business Practice Location Address
First Line	:	108 FINNEGAN CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-4205
Country	:	US
Telephone Number	:	843-909-9993
Fax Number	:	843-903-3366

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	01/15/2014

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