Provider Demographics
NPI:1245232248
Name:VIDALS, VICTOR GUILLERMO (MD)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:GUILLERMO
Last Name:VIDALS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1004 CARONDELET DR
Mailing Address - Street 2:SUITE 460
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4802
Mailing Address - Country:US
Mailing Address - Phone:816-942-8250
Mailing Address - Fax:816-942-7206
Practice Address - Street 1:1004 CARONDELET DR
Practice Address - Street 2:SUITE 460
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4802
Practice Address - Country:US
Practice Address - Phone:816-942-8250
Practice Address - Fax:816-942-7206
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOMDR3433208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000013902Medicaid
MOC51914Medicare UPIN
MO4771101Medicare ID - Type Unspecified