Provider Demographics
NPI:1790995363
Name:VIDAL, WANDA IVETTE (MD)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:IVETTE
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MD
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 160
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-0160
Mailing Address - Country:US
Mailing Address - Phone:787-863-3412
Mailing Address - Fax:787-655-5024
Practice Address - Street 1:AVE. GENERAL VALERO #404
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-655-0505
Practice Address - Fax:787-655-5024
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15408208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice