Provider Demographics
NPI:1538304720
Name:VIDALE, MARC M (IDC)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:M
Last Name:VIDALE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 SENN RD
Mailing Address - Street 2:SUITE 7 BLDG 55
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3325 SENN RD
Practice Address - Street 2:SUITE 7 BLDG 55
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5029
Practice Address - Country:US
Practice Address - Phone:619-556-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman