Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | DR.0031693 | CO |
NPI | 1083685515 |
---|---|
Provider Name | Michael C Vidas |
First Address | Broomfield, CO 80021-8252 |
Second Address | Broomfield, CO 80021-8252 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2006 |
Last Update Date | 21/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7215792 | BCBS (01) | |
C44026 | (02) |