Provider Demographics
NPI:1639122195
Name:VIDRINE, CALVIN DALE (CRA RJ RN)
Entity Type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:DALE
Last Name:VIDRINE
Suffix:
Gender:M
Credentials:CRA RJ RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70571-1939
Mailing Address - Country:US
Mailing Address - Phone:337-942-1915
Mailing Address - Fax:337-942-1990
Practice Address - Street 1:174 GRANT RD
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0720
Practice Address - Country:US
Practice Address - Phone:337-594-9637
Practice Address - Fax:337-948-4556
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA100410052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664669Medicaid
LA2000777340OtherBCBS
LA1664669Medicaid
LA5CA29Medicare ID - Type Unspecified