Provider Demographics
NPI:1013955434
Name:VIDAURRI, ELISA G (PT)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:G
Last Name:VIDAURRI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 EMBASSY OAKS
Mailing Address - Street 2:202
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2040
Mailing Address - Country:US
Mailing Address - Phone:210-490-4738
Mailing Address - Fax:210-490-5231
Practice Address - Street 1:415 EMBASSY OAKS
Practice Address - Street 2:202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2040
Practice Address - Country:US
Practice Address - Phone:210-490-4738
Practice Address - Fax:210-490-5231
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1132140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7981357OtherAETNA
TX1132140OtherLICENSE NUMBER