Provider Demographics
NPI:1578078838
Name:WIDEMAN, JOSHUA DANIEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:DANIEL
Last Name:WIDEMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3986 MARYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4191
Mailing Address - Country:US
Mailing Address - Phone:618-797-0618
Mailing Address - Fax:
Practice Address - Street 1:3986 MARYVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4191
Practice Address - Country:US
Practice Address - Phone:618-797-0618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017014934111N00000X
IL038.013405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor