Provider Demographics
NPI:1629157003
Name:WIDER, TODD M (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:M
Last Name:WIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:TODD
Other - Middle Name:M
Other - Last Name:WIDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:48 ROUTE 25A
Mailing Address - Street 2:202
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1431
Mailing Address - Country:US
Mailing Address - Phone:631-862-3625
Mailing Address - Fax:631-862-3347
Practice Address - Street 1:871 5TH AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:212-772-1229
Practice Address - Fax:212-737-8569
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1936022086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G33228Medicare UPIN