Basic Information
| Provider Information | |||||||||
| NPI: | 1780605345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAL | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | MIGUEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ST. 46 SW #1410 | ||||||||
| Address2: | LA RIVIERA | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877397846 | ||||||||
| FaxNumber: | 7876533112 | ||||||||
| Practice Location | |||||||||
| Address1: | HOSPITAL HIMA SAN PABLO CAGUAS | ||||||||
| Address2: | AVE LUIS MUNOZ MARIN | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876533434 | ||||||||
| FaxNumber: | 7876533112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | 9192 | PR | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8-3244 | 01 | PR | SSS | OTHER |