Provider Demographics
NPI:1073048963
Name:WIDDER, JARED ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:ROBERT
Last Name:WIDDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:619-532-7272
Practice Address - Street 1:100 STEIN PLZ FL 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-5000
Practice Address - Country:US
Practice Address - Phone:310-825-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
CA16655207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No171000000XOther Service ProvidersMilitary Health Care Provider
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN