Provider Demographics
NPI:1083685515
Name:VIDAS, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:VIDAS
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 1:403 SUMMIT BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-8252
Mailing Address - Country:US
Mailing Address - Phone:720-401-2139
Mailing Address - Fax:303-469-4439
Practice Address - Street 1:403 SUMMIT BLVD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-8252
Practice Address - Country:US
Practice Address - Phone:720-401-2139
Practice Address - Fax:303-469-4439
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0031693207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7215792OtherBCBS
774820Medicare ID - Type Unspecified
C44026Medicare UPIN