Basic Information
| Provider Information | |||||||||
| NPI: | 1104245562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDALIS | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | BENJAMIN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | MSC 10 5615 | ||||||||
| Address2: | UNIVERSITY OF NEW MEXICO | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723160 | ||||||||
| FaxNumber: | 5052729427 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059883233 | ||||||||
| FaxNumber: | 5059883562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207T00000X | MD2021-0303 | NM | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.