Provider Demographics
NPI:1306132238
Name:VIDAL, CARLOS ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ALFONSO
Last Name:VIDAL
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:PO BOX 7546
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7546
Mailing Address - Country:US
Mailing Address - Phone:787-557-7212
Mailing Address - Fax:
Practice Address - Street 1:UPR MEDICAL SCIENCES CAMPUS A-989 MAIN BUILDING
Practice Address - Street 2:APARTADO 365067
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936-5067
Practice Address - Country:US
Practice Address - Phone:787-758-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR19098207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology