Provider Demographics
NPI:1598799728
Name:EVERETT, VIVIAN DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:DENISE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:828-891-5524
Mailing Address - Fax:828-891-4069
Practice Address - Street 1:1100 NAVAHO DR
Practice Address - Street 2:SUITE 121
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7319
Practice Address - Country:US
Practice Address - Phone:919-845-4620
Practice Address - Fax:919-846-8126
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC30019208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8930948Medicaid
NC8930948Medicaid