Provider Demographics
NPI:1629205109
Name:TIZORA, SIBONOKUHLE (MD)
Entity Type:Individual
Prefix:DR
First Name:SIBONOKUHLE
Middle Name:
Last Name:TIZORA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SIBONOKUHLE
Other - Middle Name:
Other - Last Name:MAGOMBEDZE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:145 PALMETTO POINTE RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-6721
Mailing Address - Country:US
Mailing Address - Phone:843-423-2400
Mailing Address - Fax:843-423-2070
Practice Address - Street 1:145 PALMETTO POINTE RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:SC
Practice Address - Zip Code:29571-6721
Practice Address - Country:US
Practice Address - Phone:843-423-2400
Practice Address - Fax:843-423-2070
Is Sole Proprietor?:No
Enumeration Date:2009-06-11
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32285208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0365Medicaid
SCRHC013Medicaid
SC423820Medicare Oscar/Certification
SC9044Medicare PIN