Healthcare Provider Details

I. General information

NPI: 1487664454
Provider Name (Legal Business Name): JORGE ALBERTO VIDAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 19TH ST S
BIRMINGHAM AL
35249-1900
US

IV. Provider business mailing address

PO BOX 55310
BIRMINGHAM AL
35255-5310
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-8978
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberD64849
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberD64849
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberD64849
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberD64849
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberD64849
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD64849
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2007029610
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberD64849
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD64849
License Number StateMD
# 10
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberD64849
License Number StateMD
# 11
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35926
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: