Provider Demographics
NPI:1124481486
Name:VIDAL, SAMUEL J (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:VIDAL
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6105
Mailing Address - Country:US
Mailing Address - Phone:617-732-8881
Mailing Address - Fax:
Practice Address - Street 1:15 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:610-213-5273
Practice Address - Fax:610-273-5684
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-03
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA284167207RI0200X
MA275850207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty