MEDICARE: DENNIS A VIDMAR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician	MD070019L	PA
2	207N00000X	Dermatology Physician	MD070019L	PA

General Provider Information

NPI Number	:	1407856529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS A VIDMAR MD

Provider Business Mailing Address
First Line	:	10701 EAST BOULEVARD DEPARTMENT OF DERMATOLOGY
Second Line	:	VAMC WADE PARK, CLEVELAND OHIO
City	:	CLEVELAND
State	:	OH
Zip	:	44106
Country	:	US
Telephone Number	:	216-791-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	10701 EAST BOULEVARD, DEPARTMENT OF DERMATOLOGY
Second Line	:	VAMC WADE PARK
City	:	CLEVELAND
State	:	OH
Zip	:	44106-2832
Country	:	US
Telephone Number	:	216-791-3800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	05/06/2021

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