Healthcare Provider Details

I. General information

NPI: 1841466067
Provider Name (Legal Business Name): JOSEPH VIDAURRI AVITABILE PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 SUPERIOR AVE STE 200G
NEWPORT BEACH CA
92663-3664
US

IV. Provider business mailing address

12401 WASHINGTON BLVD
WHITTIER CA
90602-1006
US

V. Phone/Fax

Practice location:
  • Phone: 949-791-6767
  • Fax: 949-791-6768
Mailing address:
  • Phone: 562-698-0811
  • Fax: 789-590-2562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60821
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: