Provider Demographics
NPI:1447259684
Name:VIDAL, ADA (MD)
Entity type:Individual
Prefix:
First Name:ADA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2409
Mailing Address - Country:US
Mailing Address - Phone:203-333-6864
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:471 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-2409
Practice Address - Country:US
Practice Address - Phone:203-333-6864
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040373208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE61160Medicare UPIN