Healthcare Provider Details

I. General information

NPI: 1194717991
Provider Name (Legal Business Name): FELIPE L.G. VIDELA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 E MARYLAND AVE
PHOENIX AZ
85016-1302
US

IV. Provider business mailing address

1616 E MARYLAND AVE
PHOENIX AZ
85016-1302
US

V. Phone/Fax

Practice location:
  • Phone: 602-788-1521
  • Fax: 602-688-5420
Mailing address:
  • Phone: 602-788-1521
  • Fax: 602-688-5420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number30207
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number30207
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: