Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207T00000X | Neurosurgeon | MD2021-0303 | NM |
NPI | 1104245562 |
---|---|
Provider Name | Benjamin Vidalis |
First Address | Albuquerque, NM 87131-0001 |
Second Address | Santa Fe, NM 87505-7690 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2014 |
Last Update Date | 21/09/2021 |