Provider Demographics
NPI:1710148648
Name:TADZONG-FOMUNDAM, BI A (MD)
Entity Type:Individual
Prefix:DR
First Name:BI
Middle Name:A
Last Name:TADZONG-FOMUNDAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BI
Other - Middle Name:A
Other - Last Name:TADZONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3185 BRAMBLE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4328
Mailing Address - Country:US
Mailing Address - Phone:843-455-3585
Mailing Address - Fax:843-449-9531
Practice Address - Street 1:8170 ROURK ST STE 100
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4127
Practice Address - Country:US
Practice Address - Phone:843-449-0453
Practice Address - Fax:843-449-9531
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD365422083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine