Provider Demographics
NPI:1083635841
Name:VIDAL, OMAR DAMASO (MD)
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:DAMASO
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 1:6750 WEST LOOP SOUTH, STE 830
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401
Mailing Address - Country:US
Mailing Address - Phone:713-751-0631
Mailing Address - Fax:713-751-0605
Practice Address - Street 1:6750 WEST LOOP SOUTH, STE 830
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401
Practice Address - Country:US
Practice Address - Phone:713-751-0631
Practice Address - Fax:713-751-0605
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8553207L00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0004CGOtherMEDICARE PPMC GROUP #
TX079696301Medicaid
TX100841906OtherMEDICAID BEAUMONT
80180YOtherBCBS
TX8E0572OtherMEDICARE BEAUMONT
TX85491GOtherBC/BS BEAUMONT
TX00747YOtherBEAUMONT MEDICARE GROUP
TX0046CCOtherMEDICARE RPK GROUP #
TXP080565G5Medicaid
TXP081292GUOtherPAIN MANAGEMENT MEDICARE
TX0046CCOtherMEDICARE RPK GROUP #
TXP081292GUOtherPAIN MANAGEMENT MEDICARE