Healthcare Provider Details

I. General information

NPI: 1669409637
Provider Name (Legal Business Name): ANGEL VIDAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11880 SW 40TH ST SUITE 202
MIAMI FL
33175-3584
US

IV. Provider business mailing address

11880 SW 40TH ST SUITE 202
MIAMI FL
33175-3584
US

V. Phone/Fax

Practice location:
  • Phone: 305-552-7020
  • Fax: 305-552-7006
Mailing address:
  • Phone: 305-552-7020
  • Fax: 305-552-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberME0026606
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: