Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 13443 | WV |
NPI | 1063515054 |
---|---|
Provider Name | Melchor F Vidal |
First Address | Charleston, WV 25364-4535 |
Second Address | Racine, WV 25165 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0049855001 | (05) | WV |
D49544 | (02) | WV |