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General NPI Number Information
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NPI Number | 1396071296
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Entity Type | Organization
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Legal Business Name | J. MICHAEL VIDAL, OD INC
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Dates
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Enumeration Date | 10/27/2009
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Last Update Date | 03/08/2011
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Provider Practice Location Address
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Address Line | 7090 PARKWAY DR
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City | LA MESA
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State | CA
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Zip | 91942-1596
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Country | US
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Telephone | 619-460-2020
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Fax | 619-462-2020
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Provider Business Mailing Address
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Address Line | 7090 PARKWAY DR
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City | LA MESA
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State | CA
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Zip | 91942-1596
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Country | US
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Telephone | 619-460-2020
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Fax | 619-462-2020
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. J. MICHAEL VIDAL
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Credential | O.D.
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Telephone | 619-460-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | CA61320
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License Number State | CA
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