Provider Demographics
NPI:1588193627
Name:VIDINHA, CHAUNTELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:CHAUNTELLE
Middle Name:
Last Name:VIDINHA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4667
Mailing Address - Country:US
Mailing Address - Phone:928-753-9629
Mailing Address - Fax:
Practice Address - Street 1:3269 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:928-757-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008625207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program