Healthcare Provider Details

I. General information

NPI: 1154397263
Provider Name (Legal Business Name): JARED STEVEN VIDELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S. AUSTIN AVENUE
VENTNOR CITY NJ
08406-3012
US

IV. Provider business mailing address

115 S. AUSTIN AVENUE
VENTNOR CITY NJ
08406-3012
US

V. Phone/Fax

Practice location:
  • Phone: 609-823-1989
  • Fax:
Mailing address:
  • Phone: 609-823-1989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS-003830-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: