Provider Demographics
NPI:1770671521
Name:JACIC, AIDA (MD)
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:JACIC
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:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:803-684-3738
Mailing Address - Fax:803-684-3808
Practice Address - Street 1:1023 CREEKSIDE MEDICAL DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:SC
Practice Address - Zip Code:29745-8624
Practice Address - Country:US
Practice Address - Phone:803-684-3738
Practice Address - Fax:803-684-3808
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915465Medicaid
SC292873Medicaid
SC292873Medicaid
SCAA16548397Medicare PIN
NC5915465Medicaid