MEDICARE: OMAR D. VIDAL M.D. P.L.L.C.

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	207L00000X	Anesthesiology Physician	K8553	TX
2	208VP0000X	Pain Medicine Physician	K8553	TX
3	208VP0014X	Interventional Pain Medicine Physician	K8553	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770705865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMAR D. VIDAL M.D. P.L.L.C.

Provider Business Mailing Address
First Line	:	2105 JACKSON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77003-5839
Country	:	US
Telephone Number	:	713-751-0631
Fax Number	:	713-751-0605

Provider Business Practice Location Address
First Line	:	2105 JACKSON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77003-5839
Country	:	US
Telephone Number	:	713-751-0631
Fax Number	:	713-751-0605

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. OMAR DAMASO VIDAL
Credential	:	M.D.
Telephone Number	:	713-751-0631

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	01/07/2011

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