Basic Information
| Provider Information | |||||||||
| NPI: | 1730189192 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDEAU | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 N E ST | ||||||||
| Address2: | SUITE 331 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325016339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504441772 | ||||||||
| FaxNumber: | 8505871747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 N E ST | ||||||||
| Address2: | SUITE 331 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325016339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504441717 | ||||||||
| FaxNumber: | 8504441755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0005X | 66107 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hypertension Specialist | 207RC0000X | ME66107 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 009946875 | 05 | AL | MEDICAID | 3756599 00 | 05 | FL | MEDICAID |