Provider Demographics
NPI:1174533863
Name:VIDAL-CARDOZO, LYDIA IVETTE (PAC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:IVETTE
Last Name:VIDAL-CARDOZO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 FINNEGAN CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4205
Mailing Address - Country:US
Mailing Address - Phone:843-909-9993
Mailing Address - Fax:843-903-3366
Practice Address - Street 1:108 FINNEGAN CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4205
Practice Address - Country:US
Practice Address - Phone:843-909-9993
Practice Address - Fax:843-903-3366
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000746207Q00000X
SCPA1294363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA50828627Medicare UPIN
SC8627Medicare PIN
199LMedicare ID - Type Unspecified
S71737Medicare UPIN