Provider Demographics
NPI:1528064110
Name:VODOPALAS-PUODZIUNAS, VIDA (DC)
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:VODOPALAS-PUODZIUNAS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 66TH ST N STE 304
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5500
Mailing Address - Country:US
Mailing Address - Phone:727-550-0855
Mailing Address - Fax:727-205-8159
Practice Address - Street 1:1700 66TH ST N STE 304
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5500
Practice Address - Country:US
Practice Address - Phone:727-550-0855
Practice Address - Fax:727-205-8159
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2023-08-29
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IL038009499111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009499OtherLICENSE NUMBER
ILK18089Medicare UPIN
IL211786Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #
IL038009499OtherLICENSE NUMBER