Provider Demographics
NPI:1831195601
Name:VIDA, JAY ANDREW (DO)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:ANDREW
Last Name:VIDA
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 1:27 S COOKS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2524
Mailing Address - Country:US
Mailing Address - Phone:732-942-4455
Mailing Address - Fax:732-942-4459
Practice Address - Street 1:2125 RT 88 EAST
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3152
Practice Address - Country:US
Practice Address - Phone:732-892-4548
Practice Address - Fax:732-892-0961
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB59096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1212830001OtherMEDICARE NSC
NJ7060602Medicaid
NJ769399Medicare ID - Type Unspecified
NJ1212830001OtherMEDICARE NSC
NJ810301Medicare PIN