Provider Demographics
NPI:1174582662
Name:VIDI, RUDOLPH DANIEL (PT, MPT)
Entity type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:DANIEL
Last Name:VIDI
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1296 E BAY AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-3942
Mailing Address - Country:US
Mailing Address - Phone:609-978-1623
Mailing Address - Fax:609-978-1623
Practice Address - Street 1:279 MATHISON ROAD
Practice Address - Street 2:SOUTHERN OCEAN CENTER FOR HEALTH AT LITTLE EGG HARBOR
Practice Address - City:LITTLE EGG HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08087
Practice Address - Country:US
Practice Address - Phone:609-294-4006
Practice Address - Fax:609-812-0539
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01130800225100000X
WA6989225100000X
AZ2366225100000X
CA23864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist