Basic Information
| Provider Information | |||||||||
| NPI: | 1861598906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAILLET | ||||||||
| FirstName: | HUMBERTO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI 236 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 NE 13TH ST | ||||||||
| Address2: | 1B1409 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052718685 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 9422 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.