Healthcare Provider Details

I. General information

NPI: 1184531477
Provider Name (Legal Business Name): MICHAEL ANGELO VIDAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1087
US

IV. Provider business mailing address

10720 SW 44TH ST
MIAMI FL
33165-4837
US

V. Phone/Fax

Practice location:
  • Phone: 305-689-3362
  • Fax:
Mailing address:
  • Phone: 305-689-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835E0208X
TaxonomyEmergency Medicine Pharmacist
License NumberPS61586
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: