Healthcare Provider Details

I. General information

NPI: 1679140917
Provider Name (Legal Business Name): AMY TORA VIDALIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-0004
US

IV. Provider business mailing address

600 HIGHLAND AVE
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 227-370-6721
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number12858
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number85724-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: