Healthcare Provider Details

I. General information

NPI: 1689203440
Provider Name (Legal Business Name): KIMBERLY VIDMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-3098
US

IV. Provider business mailing address

600 HIGHLAND AVE
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-0572
  • Fax:
Mailing address:
  • Phone: 608-263-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number81889-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: