Basic Information
| Provider Information | |||||||||
| NPI: | 1538251574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAL | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660706 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752660706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
| FaxNumber: | 9704795835 | ||||||||
| Practice Location | |||||||||
| Address1: | 181 W MEADOW DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | VAIL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816575058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704761100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 43543 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26925729 | 05 | CO | MEDICAID |