Provider Demographics
NPI:1043795164
Name:VIDAL, PRIZILA DAJIA (MPSS-LIADFM)
Entity Type:Individual
Prefix:
First Name:PRIZILA
Middle Name:DAJIA
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MPSS-LIADFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 LAUREL ST PMB 531
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101
Mailing Address - Country:US
Mailing Address - Phone:619-755-4737
Mailing Address - Fax:
Practice Address - Street 1:415 LAUREL ST PMB 531
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101
Practice Address - Country:US
Practice Address - Phone:619-755-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA175T00000X
CAMPSS-LIADFM175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker