Provider Demographics
NPI:1538267679
Name:VIDAL, MELVIN THEODORE (MD)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:THEODORE
Last Name:VIDAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-8383
Mailing Address - Fax:336-718-9622
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-8383
Practice Address - Fax:336-718-9622
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC202101772207R00000X, 208M00000X
WV19970207R00000X
NC2021-01772208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706078OtherBLUE CROSS
WV7100067OtherAETNA
WV875546OtherMAMSI
WV6000357000Medicaid
WV1471766-001OtherCIGNA
WVP000095145OtherRAILROAD MEDICARE
WV1471766-001OtherCIGNA
WV875546OtherMAMSI