Provider Demographics
NPI:1225198724
Name:CHIDESTER, CANDACE C (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:C
Last Name:CHIDESTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:C
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1840 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-366-6907
Mailing Address - Fax:304-366-6216
Practice Address - Street 1:1840 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-366-6907
Practice Address - Fax:304-366-6216
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12467207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0050726000Medicaid
WV001721214OtherBC
WV0050726000Medicaid
WV001721214OtherBC