Provider Demographics
NPI:1639910748
Name:VIDAL, REINALDO (HSE 8603)
Entity type:Individual
Prefix:
First Name:REINALDO
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:HSE 8603
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16420 SW 144TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1761
Mailing Address - Country:US
Mailing Address - Phone:305-303-9180
Mailing Address - Fax:
Practice Address - Street 1:JACKSON SOUTH MEDICAL CENTER
Practice Address - Street 2:9333 SW 152 ST
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157
Practice Address - Country:US
Practice Address - Phone:305-256-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE8603208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist