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General NPI Number Information
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NPI Number | 1225491772
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Entity Type | Individual
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Provider Name | CORINNE BROOKE VIDULICH M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/01/2016
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 271 ROUTE 25A STE 2
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City | WADING RIVER
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State | NY
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Zip | 11792-2014
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Country | US
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Telephone | 631-727-4950
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Fax |
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Provider Business Mailing Address
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Address Line | 37 FRONT ST APT 5
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City | GREENPORT
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State | NY
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Zip | 11944-1639
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Country | US
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Telephone | 917-655-1312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 301007-01
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License Number State | NY
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