Provider Demographics
NPI:1073795746
Name:THE WIDEN CLINIC
Entity Type:Organization
Organization Name:THE WIDEN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:WIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM,DC
Authorized Official - Phone:770-578-1400
Mailing Address - Street 1:3535 ROSWELL RD
Mailing Address - Street 2:STE. 37
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 ROSWELL RD
Practice Address - Street 2:STE. 37
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8826
Practice Address - Country:US
Practice Address - Phone:770-578-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6040OtherMEDICARE GROUP NUMBER