Provider Demographics
NPI:1063482842
Name:VIDRIH, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:VIDRIH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1872
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:15630 18TH AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9336
Practice Address - Country:US
Practice Address - Phone:707-994-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC171245208M00000X, 207R00000X
NY332273208M00000X
MA160307207RC0200X
AZ44001208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA30305Medicare ID - Type Unspecified
MAH05974Medicare UPIN