Healthcare Provider Details

I. General information

NPI: 1396765863
Provider Name (Legal Business Name): JILL VIDAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5377 MANHATTAN CIR SUITE 201
BOULDER CO
80303-4333
US

IV. Provider business mailing address

5377 MANHATTAN CIR SUITE 201
BOULDER CO
80303-4333
US

V. Phone/Fax

Practice location:
  • Phone: 720-304-0083
  • Fax: 720-304-0114
Mailing address:
  • Phone: 720-304-0083
  • Fax: 720-304-0114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number40563
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number40563
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: