Provider Demographics
NPI:1558589101
Name:VIDAURRE, JOSE ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANGEL
Last Name:VIDAURRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4311
Mailing Address - Country:US
Mailing Address - Phone:954-491-0031
Mailing Address - Fax:
Practice Address - Street 1:3061 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4311
Practice Address - Country:US
Practice Address - Phone:954-491-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AE282ZMedicare UPIN