Provider Demographics
NPI:1578189445
Name:VIDOSH, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:VIDOSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E. MEDICAL CENTER DR.
Mailing Address - Street 2:1H247
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109
Mailing Address - Country:US
Mailing Address - Phone:734-936-4280
Mailing Address - Fax:734-936-9091
Practice Address - Street 1:1500 E. MEDICAL CENTER DR.
Practice Address - Street 2:1H247
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109
Practice Address - Country:US
Practice Address - Phone:734-936-4280
Practice Address - Fax:734-936-9091
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351046180390200000X
MI4301510510207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology