Provider Demographics
NPI:1336300771
Name:VIDGOP, YELENA (MD)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:VIDGOP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11215 METRO PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:239-208-2212
Mailing Address - Fax:239-208-3994
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:239-208-3994
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1861892084N0400X
OH35.1324382084N0400X
MS257962084N0400X
ND150202084N0400X
TXR95552084N0400X
MI43011142222084N0400X
NH187622084N0400X
PAMD4684562084N0400X
NY2968462084N0400X
FLME1154652084N0400X
FLME 1154652084N0400X
WAMD.608035152084N0400X
MO20200039272084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3115380Medicaid