Provider Demographics
NPI:1477648772
Name:VIDLAK, DANIEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
Last Name:VIDLAK
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 1:1022 NW 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526
Mailing Address - Country:US
Mailing Address - Phone:541-476-4545
Mailing Address - Fax:
Practice Address - Street 1:1022 NW 6TH STREET
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-476-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2643ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150462Medicaid
OR2643ATIOtherSTATE LICENSE
OR2643ATIOtherSTATE LICENSE
OR150462Medicaid