Provider Demographics
NPI:1689735227
Name:VIDITO, IRENA SARAH (DO)
Entity Type:Individual
Prefix:DR
First Name:IRENA
Middle Name:SARAH
Last Name:VIDITO
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 1:800 S VICTORIA AVE, L4615
Mailing Address - Street 2:VCHCA - PHYSICIAN SERVICES
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93009-0003
Mailing Address - Country:US
Mailing Address - Phone:805-677-5181
Mailing Address - Fax:805-677-5304
Practice Address - Street 1:300 HILLMONT AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1651
Practice Address - Country:US
Practice Address - Phone:805-652-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15672207RH0003X
NY207R00000X
SCTL1160207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00692297OtherRR MEDICARE
SCTL1160OtherLISCENSE
SC571050553OtherBCBS OF SOUTH CAROLINA
SC011604Medicaid
SC011604Medicaid
SCAA2878Medicare PIN
SCP00692297OtherRR MEDICARE
SCTL1160OtherLISCENSE
SCAA28786499Medicare UPIN
SCAA28787183Medicare UPIN
SCAA28786521Medicare UPIN