Provider Demographics
NPI:1376951582
Name:WIDMER, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WIDMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1173 2ND AVE
Mailing Address - Street 2:APT 3S
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-8239
Mailing Address - Country:US
Mailing Address - Phone:631-793-5327
Mailing Address - Fax:
Practice Address - Street 1:1173 2ND AVE
Practice Address - Street 2:APT 3S
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8239
Practice Address - Country:US
Practice Address - Phone:631-793-5327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency