Healthcare Provider Details

I. General information

NPI: 1578503751
Provider Name (Legal Business Name): ROSA A. VIDAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2432 67TH AVE S
ST PETERSBURG FL
33712-5613
US

IV. Provider business mailing address

2432 67TH AVE S
ST PETERSBURG FL
33712-5613
US

V. Phone/Fax

Practice location:
  • Phone: 251-454-1126
  • Fax: 727-528-6452
Mailing address:
  • Phone: 251-454-1126
  • Fax: 727-528-6452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number24595
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: