Provider Demographics
NPI:1124194451
Name:RODILLO, HEIDI ENEJOSA (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:ENEJOSA
Last Name:RODILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 968
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-0968
Mailing Address - Country:US
Mailing Address - Phone:864-366-9681
Mailing Address - Fax:864-366-5600
Practice Address - Street 1:901 W GREENWOOD ST STE 1
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29620-5727
Practice Address - Country:US
Practice Address - Phone:864-366-9681
Practice Address - Fax:864-366-5600
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
582366449OtherTAX ID
SC11698OtherSC LICENSE NUMBER
SCPC3126Medicaid
SC080085988OtherMEDICARE RAILROAD
SC116984Medicaid
SCRHC210Medicaid
SCRHC549Medicaid
SC116984Medicaid
SCGP4736Medicaid
SC3255Medicare PIN