Provider Demographics
NPI:1407427958
Name:MASTER, VIDISHA SAURABH
Entity Type:Individual
Prefix:
First Name:VIDISHA
Middle Name:SAURABH
Last Name:MASTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE BLDG 3
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3095
Mailing Address - Country:US
Mailing Address - Phone:585-922-4000
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE BLDG 3
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3095
Practice Address - Country:US
Practice Address - Phone:585-922-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty