Provider Demographics
NPI:1679004469
Name:WIDEBURG, ERIC (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:WIDEBURG
Suffix:
Gender:M
Credentials:DO
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 713121
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0321
Mailing Address - Country:US
Mailing Address - Phone:262-292-3151
Mailing Address - Fax:262-643-4707
Practice Address - Street 1:10945 N PORT WASHINGTON RD STE 201
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53092-5078
Practice Address - Country:US
Practice Address - Phone:262-292-3151
Practice Address - Fax:262-643-4707
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72422-212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology