Provider Demographics
NPI:1225491772
Name:VIDULICH, CORINNE BROOKE (MD)
Entity type:Individual
Prefix:DR
First Name:CORINNE
Middle Name:BROOKE
Last Name:VIDULICH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 FRONT ST APT 5
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-1639
Mailing Address - Country:US
Mailing Address - Phone:917-655-1312
Mailing Address - Fax:
Practice Address - Street 1:271 ROUTE 25A STE 2
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2014
Practice Address - Country:US
Practice Address - Phone:631-727-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301007-01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine