Provider Demographics
NPI:1689632697
Name:DESPRADEL, VIDAL M (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDAL
Middle Name:M
Last Name:DESPRADEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E GREENVILLE ST
Mailing Address - Street 2:SUITE 5140
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621
Mailing Address - Country:US
Mailing Address - Phone:864-716-6100
Mailing Address - Fax:864-716-6120
Practice Address - Street 1:2000 E GREENVILLE ST
Practice Address - Street 2:SUITE 5140
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-716-6100
Practice Address - Fax:864-716-6120
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058950208800000X
SC29560208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01121076OtherRR MEDICARE
SC295601Medicaid
SC295601Medicaid
SCP01121076OtherRR MEDICARE