Provider Demographics
NPI:1790755353
Name:PRIDGEN, KAORU JOAN (MD)
Entity Type:Individual
Prefix:
First Name:KAORU
Middle Name:JOAN
Last Name:PRIDGEN
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 1:7430 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2903
Mailing Address - Country:US
Mailing Address - Phone:839-200-7810
Mailing Address - Fax:803-891-7085
Practice Address - Street 1:1301 TAYLOR ST STE 5K
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2952
Practice Address - Country:US
Practice Address - Phone:839-200-7805
Practice Address - Fax:803-891-7085
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC258562Medicaid
SC258562Medicaid