Provider Demographics
NPI:1164112942
Name:VIDIC, BRANKA
Entity Type:Individual
Prefix:
First Name:BRANKA
Middle Name:
Last Name:VIDIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 MISSION INN AVE UNIT 6
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3204
Mailing Address - Country:US
Mailing Address - Phone:314-600-4359
Mailing Address - Fax:
Practice Address - Street 1:4017 MISSION INN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3204
Practice Address - Country:US
Practice Address - Phone:314-600-4359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine