Healthcare Provider Details

I. General information

NPI: 1477016210
Provider Name (Legal Business Name): SHARINA M VIDAL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 LAKE HOWELL RD
MAITLAND FL
32751-5222
US

IV. Provider business mailing address

846 LAKE HOWELL RD
MAITLAND FL
32751-5222
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-2477
  • Fax: 407-767-1627
Mailing address:
  • Phone: 407-767-2477
  • Fax: 407-767-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS18924
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: