Provider Demographics
NPI:1659698199
Name:WIDERSPAN, JANET (MD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:WIDERSPAN
Suffix:
Gender:F
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:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-0212
Mailing Address - Country:US
Mailing Address - Phone:516-804-4899
Mailing Address - Fax:
Practice Address - Street 1:50 LARCH LN
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-3924
Practice Address - Country:US
Practice Address - Phone:516-804-4899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209672207Q00000X
CAA64617207Q00000X
TXK3658207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine