Provider Demographics
NPI:1417385675
Name:VIDAFAR, KAITLIN
Entity Type:Individual
Prefix:MRS
First Name:KAITLIN
Middle Name:
Last Name:VIDAFAR
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 1:51 ROY AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7539
Mailing Address - Country:US
Mailing Address - Phone:631-513-8468
Mailing Address - Fax:
Practice Address - Street 1:538 NEW YORK 110 #202
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11174
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1076159174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist