Provider Demographics
NPI:1063515054
Name:VIDAL, MELCHOR F (MD)
Entity type:Individual
Prefix:
First Name:MELCHOR
Middle Name:F
Last Name:VIDAL
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:PO BOX 4535
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25364-4535
Mailing Address - Country:US
Mailing Address - Phone:304-837-8637
Mailing Address - Fax:
Practice Address - Street 1:27545 DANIEL BOONE PRKWY
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WV
Practice Address - Zip Code:25165
Practice Address - Country:US
Practice Address - Phone:304-837-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13443207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049855001Medicaid
WV9329151Medicare ID - Type Unspecified
WV0049855001Medicaid