Provider Demographics
NPI:1518527142
Name:VIDAL, MAGDALENE
Entity Type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17730 WEXFORD TER
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2924
Mailing Address - Country:US
Mailing Address - Phone:347-494-4896
Mailing Address - Fax:347-494-4592
Practice Address - Street 1:177 30 WEXFORD TERRACE
Practice Address - Street 2:SUITE A
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:347-494-4896
Practice Address - Fax:347-494-4592
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator