Provider Demographics
NPI:1356355747
Name:VAGNONI, ANITA MEYERS (MD)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:MEYERS
Last Name:VAGNONI
Suffix:
Gender:F
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 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-2828
Mailing Address - Fax:864-512-2265
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1000
Practice Address - Fax:864-512-1823
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059407207R00000X, 208000000X
SC36438207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC36438Medicaid
BM6312057OtherDEA
MD211828 FQHCMedicare ID - Type Unspecified
BM6312057OtherDEA
MDS865F141Medicare ID - Type Unspecified