Provider Demographics
NPI:1770865537
Name:VIDOVIC, DAVID JOHN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:VIDOVIC
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 1:1020 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4336
Mailing Address - Country:US
Mailing Address - Phone:773-671-0619
Mailing Address - Fax:
Practice Address - Street 1:347 N INDEPENDENCE BLVD
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-1558
Practice Address - Country:US
Practice Address - Phone:815-293-1152
Practice Address - Fax:815-293-1165
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-029685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist