1801645486 NPI number — MEDVIDI HEALTH PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801645486 NPI number — MEDVIDI HEALTH PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDVIDI HEALTH PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801645486
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4010 MOORPARK AVE STE 114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95117-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-966-0848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7708 RICHMOND HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22306-2803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-414-5095
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PURDY
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
910-644-8373

Provider Taxonomy Codes

  • Taxonomy code: 103TP0016X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)