Provider Demographics
NPI:1053327254
Name:VIDAL, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 PONCE DE LEON BLVD.
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146
Mailing Address - Country:US
Mailing Address - Phone:305-661-1515
Mailing Address - Fax:305-662-3723
Practice Address - Street 1:5955 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146
Practice Address - Country:US
Practice Address - Phone:305-661-1515
Practice Address - Fax:305-662-3723
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ063816207PE0004X
FLME808772080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7973403Medicaid
FL279761500Medicaid
FL279761500Medicaid
NJ059488Medicare ID - Type Unspecified