Provider Demographics
NPI:1205015906
Name:WIDITZ, DAVID FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:FREDERICK
Last Name:WIDITZ
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 1:421 W BROADWAY STE 302
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9046
Mailing Address - Country:US
Mailing Address - Phone:319-208-2744
Mailing Address - Fax:319-208-2627
Practice Address - Street 1:421 W BROADWAY STE 302
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9046
Practice Address - Country:US
Practice Address - Phone:319-208-2744
Practice Address - Fax:319-208-2627
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361669422084P0800X, 2084P0804X
IA373382084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA363616314Medicaid