Provider Demographics
NPI:1982691796
Name:WIDEMAN, VANESSA K (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:K
Last Name:WIDEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1325 S CAROLINA RD STE 11
Mailing Address - Street 2:
Mailing Address - City:EASTOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29044-5000
Mailing Address - Country:US
Mailing Address - Phone:803-647-8295
Mailing Address - Fax:803-647-8612
Practice Address - Street 1:1325 S CAROLINA RD STE 11
Practice Address - Street 2:
Practice Address - City:EASTOVER
Practice Address - State:SC
Practice Address - Zip Code:29044
Practice Address - Country:US
Practice Address - Phone:803-647-8295
Practice Address - Fax:803-647-8612
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC29480207Q00000X
AL0023629207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCI-72928Medicare UPIN