Basic Information
| Provider Information | |||||||||
| NPI: | 1871604322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LISA D. VIDATO, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD | ||||||||
| Address2: | #440 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
| FaxNumber: | 3104713958 | ||||||||
| Practice Location | |||||||||
| Address1: | 1328 22ND ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108298202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | VIDATO | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3108298202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G68685 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G686850 | 05 | CA | MEDICAID |