Healthcare Provider Details

I. General information

NPI: 1003120692
Provider Name (Legal Business Name): ANDRIJA VIDIC D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE STE 700
ORLANDO FL
32804-5521
US

IV. Provider business mailing address

2415 N ORANGE AVE STE 700
ORLANDO FL
32804-5521
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2474
  • Fax: 407-303-0680
Mailing address:
  • Phone: 407-303-2474
  • Fax: 407-303-0680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number9759853-1204
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberOS14450
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: