Provider Demographics
NPI:1043318199
Name:VIDEEN, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:VIDEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4225 EXECUTIVE SQ STE 450
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-8411
Mailing Address - Country:US
Mailing Address - Phone:858-810-0000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:752 MEDICAL CENTER CT
Practice Address - Street 2:SUITE 302
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6658
Practice Address - Country:US
Practice Address - Phone:619-421-3361
Practice Address - Fax:619-656-8936
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2021-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG59271207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G592710Medicaid
CABD830SOtherSO. CALIFORNIA PTAN
CACA108496OtherNO. CALIFORNIA PTAN
CACA108496OtherNO. CALIFORNIA PTAN
CAA93532Medicare UPIN