Provider Demographics
NPI:1619644234
Name:VIDARTE, JORGE LUIS
Entity Type:Individual
Prefix:MRS
First Name:JORGE
Middle Name:LUIS
Last Name:VIDARTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 WALNUT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3144
Mailing Address - Country:US
Mailing Address - Phone:650-554-0856
Mailing Address - Fax:
Practice Address - Street 1:772 WALNUT ST APT 3
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3144
Practice Address - Country:US
Practice Address - Phone:650-554-0856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health