Provider Demographics
NPI:1720060254
Name:VIDETTO, JEFFREY JOSEPH (PT)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:VIDETTO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:328 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2225
Mailing Address - Country:US
Mailing Address - Phone:802-447-2101
Mailing Address - Fax:802-447-1902
Practice Address - Street 1:328 DEWEY ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2225
Practice Address - Country:US
Practice Address - Phone:802-447-2101
Practice Address - Fax:802-447-1902
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0000818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT43169OtherMOHAWK VALLEY PLAN
VT2775OtherBCBS OF VT
VT2775OtherBCBS OF VT