Provider Demographics
NPI:1326273947
Name:VIDOVICH-ORTIZ, ANDRES (MD)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:VIDOVICH-ORTIZ
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:PO BOX 2667
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-2667
Mailing Address - Country:US
Mailing Address - Phone:813-866-1959
Mailing Address - Fax:813-866-1957
Practice Address - Street 1:19105 N US HIGHWAY 41
Practice Address - Street 2:SUITE 300
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-4206
Practice Address - Country:US
Practice Address - Phone:813-866-1959
Practice Address - Fax:813-866-1957
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009005331208600000X
FLME 102230208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery