Provider Demographics
NPI:1942367032
Name:VIDAL, HEIDI R (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:R
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HEIDI
Other - Middle Name:R
Other - Last Name:DEANTONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:404 TATUM ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3499
Mailing Address - Country:US
Mailing Address - Phone:856-845-8050
Mailing Address - Fax:856-845-0688
Practice Address - Street 1:404 TATUM ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3499
Practice Address - Country:US
Practice Address - Phone:856-845-8050
Practice Address - Fax:856-845-0688
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA078612002084P0800X, 2084P0804X
PAMD061470L2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ090220ZEJZMedicare PIN
NJ090220ZEJZMedicare PIN