Provider Demographics
NPI:1376524173
Name:VIDAL, PAUL GREGORY (DPT)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:GREGORY
Last Name:VIDAL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 YARMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-6267
Mailing Address - Country:US
Mailing Address - Phone:856-608-1740
Mailing Address - Fax:
Practice Address - Street 1:1930 MARLTON PIKE E
Practice Address - Street 2:A-7
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2150
Practice Address - Country:US
Practice Address - Phone:856-424-0993
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA008945002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ080273T1ZMedicare PIN