Provider Demographics
NPI:1740277011
Name:CHADBOURNE, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:CHADBOURNE
Suffix:
Gender:M
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 887
Mailing Address - Street 2:
Mailing Address - City:ABBEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29620-0887
Mailing Address - Country:US
Mailing Address - Phone:864-366-7902
Mailing Address - Fax:864-366-6062
Practice Address - Street 1:135 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-2558
Practice Address - Country:US
Practice Address - Phone:864-882-8074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101371-85208800000X
SC81829208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4449Medicaid
10444433OtherCAQH
SC818299Medicaid