Provider Demographics
NPI:1184657298
Name:VIDAL, GUSTAVO (PT)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 LITCHBOROUGH WAY
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3612
Mailing Address - Country:US
Mailing Address - Phone:919-600-4309
Mailing Address - Fax:919-694-6417
Practice Address - Street 1:123 CAPCOM AVE STE 2
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6517
Practice Address - Country:US
Practice Address - Phone:919-551-4142
Practice Address - Fax:919-694-6417
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8191174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC078M3OtherBCBS PROVIDER NUMBER