Active NPI
Gustavo Vidal, PT
- Specialist
- Wake Forest, NC
National Provider Identifier
1184657298
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Specialist
- License
- 8191
- Practice address
- 123 Capcom Ave Ste 2
Wake Forest, NC 27587-6517 - Phone
- (919) 551-4142
- Fax
- (919) 694-6417
- NPI assigned
- Jul 9, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 8191 | NC | Primary |
Addresses
Primary practice location
123 Capcom Ave Ste 2
Wake Forest, NC 27587-6517
Mailing address
1333 Litchborough Way
Wake Forest, NC 27587-3612
Phone (919) 600-4309
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 078M3 | Other | NC | BCBS PROVIDER NUMBER |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 8191 | NC | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152403200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1708300800000",
"number": "1184657298",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1333 LITCHBOROUGH WAY",
"city": "WAKE FOREST",
"state": "NC",
"postal_code": "275873612",
"telephone_number": "919-600-4309",
"fax_number": "919-694-6417"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "123 CAPCOM AVE STE 2",
"city": "WAKE FOREST",
"state": "NC",
"postal_code": "275876517",
"telephone_number": "919-551-4142",
"fax_number": "919-694-6417"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VIDAL",
"first_name": "GUSTAVO",
"name_prefix": "Mr.",
"credential": "PT",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-09",
"last_updated": "2024-02-19",
"certification_date": "2024-02-19",
"status": "A"
},
"taxonomies": [
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "NC",
"license": "8191",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS PROVIDER NUMBER",
"identifier": "078M3",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Wake Forest, NC
- Alicia Lauren Varone, OTR/L
- Elizabeth Vaughan, MSN, APRN, CPNP-PC
- Jackelin Jennifer Veloz-Jefferson, EDS
- Verity Therapeutic Services, PLLC
- Minnie Simmons Vickers, MSW, LCSWA
- Village Family Care of Wake Forest PA
- Village Pharmacy of Wake Forest LLC
- Village Pharmacy of Wake Forest, LLC
- Britt D Vinson, DDS
- Vital Touch Home Care Incorporated
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.