Provider Demographics
NPI:1891893848
Name:JOHN VIDEEN MD,INC
Entity Type:Organization
Organization Name:JOHN VIDEEN MD,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-316-9142
Mailing Address - Street 1:PO BOX 121957
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91912-6657
Mailing Address - Country:US
Mailing Address - Phone:619-421-3361
Mailing Address - Fax:619-656-8936
Practice Address - Street 1:752 MEDICAL CENTER CT
Practice Address - Street 2:SUITE 210
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6658
Practice Address - Country:US
Practice Address - Phone:619-421-3361
Practice Address - Fax:619-656-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G592710Medicaid
CAWG59271HMedicare ID - Type UnspecifiedMEDICARE
CA00G592710Medicaid