Provider Demographics
NPI:1770119471
Name:LEON VIDAL, LISSET
Entity type:Individual
Prefix:
First Name:LISSET
Middle Name:
Last Name:LEON VIDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 W 16TH AVE # LOTE10
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4646
Mailing Address - Country:US
Mailing Address - Phone:786-599-2407
Mailing Address - Fax:
Practice Address - Street 1:3131 W 16TH AVE # LOTE10
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4646
Practice Address - Country:US
Practice Address - Phone:786-599-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20155246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant