Provider Demographics
NPI:1003429432
Name:PATEL, VIDISHA
Entity Type:Individual
Prefix:
First Name:VIDISHA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13989 LANDSTAR BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-5501
Mailing Address - Country:US
Mailing Address - Phone:407-888-9868
Mailing Address - Fax:407-888-9895
Practice Address - Street 1:13989 LANDSTAR BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-5501
Practice Address - Country:US
Practice Address - Phone:078-889-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist