Basic Information
Provider Information | |||||||||
NPI: | 1477546075 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VIDAL | ||||||||
FirstName: | JOSE | ||||||||
MiddleName: | FRANCISCO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8109 FREDERICKSBURG RD | ||||||||
Address2: | PHYSICIAN PRACTICE SERVICES | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782293311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105758229 | ||||||||
FaxNumber: | 2105758127 | ||||||||
Practice Location | |||||||||
Address1: | 8026 FLOYD CURL | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782293915 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105758229 | ||||||||
FaxNumber: | 2105758127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2005 | ||||||||
LastUpdateDate: | 07/04/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | L4158 | TX | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | L4158 | TX | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 172066604 | 05 | TX |   | MEDICAID | 8DJ871 | 01 | TX | BCBS | OTHER | P00951171 | 01 | TX | RAILROAD | OTHER | 172066602 | 05 | TX |   | MEDICAID | 172066605 | 05 | TX |   | MEDICAID | 8CU839 | 01 |   | BCBS TX | OTHER |