Provider Demographics
NPI:1083687859
Name:SHEEN, VIDAL T (MD)
Entity Type:Individual
Prefix:
First Name:VIDAL
Middle Name:T
Last Name:SHEEN
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 1:16974 RIVERDALE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-4474
Mailing Address - Country:US
Mailing Address - Phone:314-842-1441
Mailing Address - Fax:314-842-1402
Practice Address - Street 1:11144 TESSON FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6965
Practice Address - Country:US
Practice Address - Phone:314-842-1441
Practice Address - Fax:314-842-1402
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1086042086S0129X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2665001OtherMEDICARE PTAN
MO203819214Medicaid
MOP00695170OtherMEDICARE RAILROAD
MODT0542OtherMEDICARE RAILROAD GROUP PTAN
MODT0542OtherMEDICARE RAILROAD GROUP PTAN
G80151Medicare UPIN