Healthcare Provider Details

I. General information

NPI: 1255120101
Provider Name (Legal Business Name): EDREE VIDAL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 4TH ST
SAN FRANCISCO CA
94143-2351
US

IV. Provider business mailing address

136 MAJESTIC AVE
SAN FRANCISCO CA
94112-3022
US

V. Phone/Fax

Practice location:
  • Phone: 832-818-1487
  • Fax:
Mailing address:
  • Phone: 832-818-1487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number95237747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: