Healthcare Provider Details

I. General information

NPI: 1962106740
Provider Name (Legal Business Name): MICHAEL VIDAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 JESSE JEWELL PKWY NE STE 301
GAINESVILLE GA
30501-3806
US

IV. Provider business mailing address

743 SPRING ST NE STE 710
GAINESVILLE GA
30501-3715
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-0023
  • Fax:
Mailing address:
  • Phone: 770-219-8730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number111782
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: