Basic Information
| Provider Information | |||||||||
| NPI: | 1285601344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIDA | ||||||||
| FirstName: | MAURICE | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 295 WHARTON LN | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766790321 | ||||||||
| FaxNumber: | 2766796498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0102049965 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006084877 | 05 | VA | MEDICAID |