Healthcare Provider Details

I. General information

NPI: 1083685515
Provider Name (Legal Business Name): MICHAEL C VIDAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SUMMIT BLVD
BROOMFIELD CO
80021-8252
US

IV. Provider business mailing address

403 SUMMIT BLVD
BROOMFIELD CO
80021-8252
US

V. Phone/Fax

Practice location:
  • Phone: 720-401-2139
  • Fax: 303-469-4439
Mailing address:
  • Phone: 720-401-2139
  • Fax: 303-469-4439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberDR.0031693
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: