Individual
MR. GUSTAVO VIDAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
123 CAPCOM AVE STE 2, WAKE FOREST, NC 27587-6517
(919) 551-4142
(919) 694-6417
Mailing address
1333 LITCHBOROUGH WAY, WAKE FOREST, NC 27587-3612
(919) 600-4309
(919) 694-6417
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
8191
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
078M3
BCBS PROVIDER NUMBER
NC
Enumeration date
07/09/2006
Last updated
02/19/2024
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