Provider Demographics
NPI:1033509757
Name:WIDMARK, DOUGLAS JAMES
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JAMES
Last Name:WIDMARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 CINNAMON RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-4836
Mailing Address - Country:US
Mailing Address - Phone:775-741-7982
Mailing Address - Fax:
Practice Address - Street 1:8390 CINNAMON RIDGE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-4836
Practice Address - Country:US
Practice Address - Phone:775-741-7982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner