Provider Demographics
NPI:1114416708
Name:VIDAL, CHARLIE (MD, MPH, MBA)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:MD, MPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ST IN PUERTO RICO
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 ST IN PUERTO RICO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-242-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2023-03-15
Deactivation Date:2022-04-18
Deactivation Code:
Reactivation Date:2022-12-15
Provider Licenses
StateLicense IDTaxonomies
PR16158-I208D00000X
PR390200000X, 261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program