=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598984841
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MELVIN T VIDAL MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 11/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1313 QUARRIER ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25301-6002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-720-2060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1055
-----------------------------------------------------
City | SCOTT DEPOT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25560-1055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-720-2060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELVIN T VIDAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 304-720-2060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 19970
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------