Healthcare Provider Details

I. General information

NPI: 1952700270
Provider Name (Legal Business Name): MARCO VIDALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE PASCUAL ORTIZ RUBIO #999 LOCAL C COL. MEDARDO GLZ
REYNOSA TAMAULIPAS
88550
MX

IV. Provider business mailing address

CALLE PASCUAL ORTIZ RUBIO #999 LOCAL C COL. MEDARDO GLZ
REYNOSA TAMAULIPAS
88550
MX

V. Phone/Fax

Practice location:
  • Phone: 899-922-9121
  • Fax:
Mailing address:
  • Phone: 899-922-9121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number2280197
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: