Provider Demographics
NPI:1437750106
Name:VIDAURRE, DAVID MAURICIO
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MAURICIO
Last Name:VIDAURRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ALGONQUIN TRL
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4579
Mailing Address - Country:US
Mailing Address - Phone:203-362-7552
Mailing Address - Fax:
Practice Address - Street 1:175 W 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3203
Practice Address - Country:US
Practice Address - Phone:877-996-2326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5185104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker