Provider Demographics
NPI:1336120484
Name:JOHN PAUL VIDOLIN M D P A
Entity Type:Organization
Organization Name:JOHN PAUL VIDOLIN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-497-1771
Mailing Address - Street 1:STE 102
Mailing Address - Street 2:836 SUNSET LAKE BLVD
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-7555
Mailing Address - Country:US
Mailing Address - Phone:941-497-1771
Mailing Address - Fax:941-497-1860
Practice Address - Street 1:836 SUNSET LAKE BLVD
Practice Address - Street 2:STE 102
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7555
Practice Address - Country:US
Practice Address - Phone:941-497-1771
Practice Address - Fax:941-497-1860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45975OtherBC BS OF FLORIDA
FL3925180001Medicare NSC
FLCH8966Medicare PIN
FLF75881Medicare UPIN
FLK2847Medicare PIN
FL200040286Medicare PIN