Provider Demographics
NPI:1831973809
Name:VIDETTO, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:VIDETTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 CITY CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-1686
Mailing Address - Country:US
Mailing Address - Phone:781-361-5978
Mailing Address - Fax:
Practice Address - Street 1:2150 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302
Practice Address - Country:US
Practice Address - Phone:303-492-8337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.00193632251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic