Provider Demographics
NPI:1063704914
Name:VIDOR, NICHOLAS BRIAN (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRIAN
Last Name:VIDOR
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 1:20 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-9702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 5TH ST SE
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-9702
Practice Address - Country:US
Practice Address - Phone:218-666-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1063704914Medicaid
0001-0100257OtherMEDICA
MN1063704914OtherBCBS
MNP01099801OtherRR MEDICARE
MN1063704914Medicaid