Provider Demographics
NPI:1225566953
Name:WIDNER, JUSTIN WADE (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WADE
Last Name:WIDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:1610 TAZEWELL RD STE 203
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-3648
Practice Address - Country:US
Practice Address - Phone:423-259-3701
Practice Address - Fax:866-954-5783
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN3903208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ042576Medicaid