Provider Demographics
NPI:1376741769
Name:DE FREITES VIDAL, KATY (MD)
Entity Type:Individual
Prefix:DR
First Name:KATY
Middle Name:
Last Name:DE FREITES VIDAL
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:PO BOX 1688
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-1688
Mailing Address - Country:US
Mailing Address - Phone:787-642-6291
Mailing Address - Fax:
Practice Address - Street 1:EDIF PARRAS STE 708
Practice Address - Street 2:PONCE BY PASS
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1321
Practice Address - Country:US
Practice Address - Phone:787-812-3792
Practice Address - Fax:787-812-3794
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRPR16652208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR16652OtherPR MEDICAL DOCTOR