Provider Demographics
NPI:1043037625
Name:FOX, GWENDOLYN (DR)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 TRADERS CROSS STE 217
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-4637
Mailing Address - Country:US
Mailing Address - Phone:843-376-1257
Mailing Address - Fax:843-376-9198
Practice Address - Street 1:110 TRADERS CROSS STE 217
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-4637
Practice Address - Country:US
Practice Address - Phone:843-376-1257
Practice Address - Fax:843-376-9198
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-2174171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor