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NPI Code Detail

MEDICARE: DR. GARY LEE VIDOR PH.D.

MEDICARE: DR. GARY LEE VIDOR PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologistPSY 5219CA

General Provider Information

NPI Number : 1902872872
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. GARY LEE VIDOR PH.D.
Provider Business Mailing Address
First Line : 21 HIDDEN VALLEY RD STE 10
Second Line :
City : MONROVIA
State : CA
Zip : 91016-1601
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 50 N HILL AVE STE 202
Second Line :
City : PASADENA
State : CA
Zip : 91106-1949
Country : US
Telephone Number : 626-739-8388
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/28/2006
Last Update Date : 09/05/2024

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