Provider Demographics
NPI:1164454278
Name:WIDSTROM, CHRISTOPHER J (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:WIDSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 CONNECTICUT AVE. S
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377
Mailing Address - Country:US
Mailing Address - Phone:320-259-4100
Mailing Address - Fax:320-259-8044
Practice Address - Street 1:1901 CONNECTICUT AVE. S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-259-4100
Practice Address - Fax:320-259-8044
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36764207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN311865700Medicaid
MN209000598Medicare ID - Type Unspecified
MN0248810001Medicare NSC
MN311865700Medicaid