Healthcare Provider Details

I. General information

NPI: 1104245562
Provider Name (Legal Business Name): BENJAMIN VIDALIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BENJAMIN WILSON

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 SAINT MICHAELS DR STE 107
SANTA FE NM
87505-7690
US

IV. Provider business mailing address

MSC 10 5615 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-3233
  • Fax: 505-988-3562
Mailing address:
  • Phone: 505-272-3160
  • Fax: 505-272-9427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD2021-0303
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: