Provider Demographics
NPI:1457311128
Name:VIDAL, J MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:J MICHAEL
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7090 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1596
Mailing Address - Country:US
Mailing Address - Phone:619-460-2020
Mailing Address - Fax:619-462-2020
Practice Address - Street 1:7090 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1596
Practice Address - Country:US
Practice Address - Phone:619-460-2020
Practice Address - Fax:619-462-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA61320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0061320Medicaid
CACR773ZMedicare PIN