Provider Demographics
NPI:1093796286
Name:VIDAL, JUAN (MD)
Entity Type:Individual
Prefix:MR
First Name:JUAN
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 1:312 S OLD DIXIE HWY
Mailing Address - Street 2:STE 107
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7489
Mailing Address - Country:US
Mailing Address - Phone:561-935-9622
Mailing Address - Fax:561-935-9627
Practice Address - Street 1:312 S OLD DIXIE HWY STE 107
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7489
Practice Address - Country:US
Practice Address - Phone:561-935-9622
Practice Address - Fax:561-935-9627
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70026207R00000X
FLME 70026207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31827CMedicare ID - Type Unspecified
FLF54914Medicare UPIN