Provider Demographics
NPI:1548380181
Name:YOUNG, DIERDRE TANECIA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIERDRE
Middle Name:TANECIA
Last Name:YOUNG
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 1:506 E CHEVES ST STE 202
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2616
Mailing Address - Country:US
Mailing Address - Phone:843-777-7341
Mailing Address - Fax:843-777-7345
Practice Address - Street 1:800 E CHEVES ST STE 400
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2649
Practice Address - Country:US
Practice Address - Phone:843-777-7341
Practice Address - Fax:843-777-7345
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01897207R00000X
SC82454207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00448200OtherRR MEDICARE
NC14704OtherBCBS
SCNP0935Medicaid
NC5908662Medicaid
NC5908662Medicaid