Provider Demographics
NPI:1427039569
Name:VIDOLIN, JOHN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN PAUL
Middle Name:
Last Name:VIDOLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN PAUL
Other - Middle Name:
Other - Last Name:VIDOLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD PA
Mailing Address - Street 1:836 SUNSET LAKE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-7554
Mailing Address - Country:US
Mailing Address - Phone:941-497-1771
Mailing Address - Fax:941-497-1860
Practice Address - Street 1:836 SUNSET LAKE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7554
Practice Address - Country:US
Practice Address - Phone:941-497-1771
Practice Address - Fax:941-497-1860
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068375207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27192OtherBCBS
FL27192ZOtherMEDICARE PROVIDER
3925180001OtherPALMETTO GBA
FL27192OtherBCBS