Provider Demographics
NPI:1952700270
Name:VIDALES, MARCO
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:VIDALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE PASCUAL ORTIZ RUBIO #999 LOCAL C COL. MEDARDO GLZ
Mailing Address - Street 2:
Mailing Address - City:REYNOSA
Mailing Address - State:TAMAULIPAS
Mailing Address - Zip Code:88550
Mailing Address - Country:MX
Mailing Address - Phone:899-922-9121
Mailing Address - Fax:
Practice Address - Street 1:CALLE PASCUAL ORTIZ RUBIO #999 LOCAL C COL. MEDARDO GLZ
Practice Address - Street 2:
Practice Address - City:REYNOSA
Practice Address - State:TAMAULIPAS
Practice Address - Zip Code:88550
Practice Address - Country:MX
Practice Address - Phone:899-922-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ22801972080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology