Provider Demographics
NPI:1386810794
Name:VIDD, JEROME RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:RICHARD
Last Name:VIDD
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 1:795 NAUTILUS TRAIL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OH
Mailing Address - Zip Code:44202-8901
Mailing Address - Country:US
Mailing Address - Phone:216-233-1940
Mailing Address - Fax:330-562-5890
Practice Address - Street 1:795 NAUTILUS TRAIL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-8901
Practice Address - Country:US
Practice Address - Phone:216-233-1940
Practice Address - Fax:330-562-5890
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine