Provider Demographics
NPI:1750397196
Name:VIDAL, VANESSA I (MD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:I
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:20 HOPE AVE
Mailing Address - Street 2:SUITE G10
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2721
Mailing Address - Country:US
Mailing Address - Phone:781-647-6920
Mailing Address - Fax:781-891-0056
Practice Address - Street 1:20 HOPE AVE
Practice Address - Street 2:SUITE G10
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2721
Practice Address - Country:US
Practice Address - Phone:781-647-6920
Practice Address - Fax:781-891-0056
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA229164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA495592OtherTUFTS
MAAA78063OtherHPHC
MAJ41183OtherBLUE CROSS
MA2124939Medicaid
MAJ41183OtherBLUE CROSS