Provider Demographics
NPI:1720518384
Name:CUNDIFF, NICHOLAS MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MATTHEW
Last Name:CUNDIFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6366
Mailing Address - Country:US
Mailing Address - Phone:803-254-3676
Mailing Address - Fax:803-254-3678
Practice Address - Street 1:457 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2766
Practice Address - Country:US
Practice Address - Phone:843-781-7428
Practice Address - Fax:843-781-7429
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC41060208000000X
FLOS19436208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC910759Medicaid