Provider Demographics
NPI:1437248630
Name:VIDAL, MARTHA G (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:G
Last Name: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 1:1601 N SEPULVEDA BLVD # 400
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5111
Mailing Address - Country:US
Mailing Address - Phone:323-755-5500
Mailing Address - Fax:323-755-5522
Practice Address - Street 1:11502 S VERMONT AVE STE B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-6522
Practice Address - Country:US
Practice Address - Phone:323-755-5500
Practice Address - Fax:323-755-5522
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78069207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A780690Medicaid