Provider Demographics
NPI:1154397263
Name:VIDELL, JARED STEVEN (DO)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:STEVEN
Last Name:VIDELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S. AUSTIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:VENTNOR CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08406-3012
Mailing Address - Country:US
Mailing Address - Phone:609-823-1989
Mailing Address - Fax:
Practice Address - Street 1:115 S. AUSTIN AVENUE
Practice Address - Street 2:
Practice Address - City:VENTNOR CITY
Practice Address - State:NJ
Practice Address - Zip Code:08406-3012
Practice Address - Country:US
Practice Address - Phone:609-823-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-003830-L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB35429Medicare UPIN
PA089922Medicare ID - Type Unspecified