Healthcare Provider Details

I. General information

NPI: 1699736165
Provider Name (Legal Business Name): JORGE ALBERTO VIDAURRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S 18TH ST
COLUMBUS OH
43205-2696
US

IV. Provider business mailing address

555 S 18TH ST
COLUMBUS OH
43205-2696
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-6200
  • Fax:
Mailing address:
  • Phone: 614-722-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number35087257
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number35087257
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number35087257
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: