Provider Demographics
NPI:1033639877
Name:VIDAD, JOHNEL (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHNEL
Middle Name:
Last Name:VIDAD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16820 WEST RD # 3
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-5577
Mailing Address - Country:US
Mailing Address - Phone:281-856-7008
Mailing Address - Fax:281-856-7108
Practice Address - Street 1:16820 WEST RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-5577
Practice Address - Country:US
Practice Address - Phone:832-212-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2060899225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2251500000XMedicaid