Provider Demographics
NPI:1194875252
Name:VIDAIC, DANIEL SIME (DPT)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SIME
Last Name:VIDAIC
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:ORADELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07649-1719
Mailing Address - Country:US
Mailing Address - Phone:201-262-5840
Mailing Address - Fax:
Practice Address - Street 1:15-01 BROADWAY
Practice Address - Street 2:SUITE 30A
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6003
Practice Address - Country:US
Practice Address - Phone:201-703-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00904900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist