Healthcare Provider Details

I. General information

NPI: 1114416708
Provider Name (Legal Business Name): CHARLIE VIDAL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date: 04/18/2022
Reactivation Date: 12/15/2022

III. Provider practice location address

CALLE DR. CUETO #70
UTUADO PR
00641
US

IV. Provider business mailing address

CALLE HERNANDEZ CARRION
MANATI PR
00674
US

V. Phone/Fax

Practice location:
  • Phone: 860-578-4969
  • Fax:
Mailing address:
  • Phone: 787-621-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25043
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: