Provider Demographics
NPI:1700838968
Name:WIDES, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WIDES
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4342
Practice Address - Street 1:500 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-3306
Practice Address - Country:US
Practice Address - Phone:304-332-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15161WV207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010275598Medicaid
WV000023444OtherBLUE CROSS BLUE SHIELD
WV3001599OtherBRICKSTREET
WV0071366000Medicaid
WV0071366000Medicaid
WV3001599OtherBRICKSTREET
WVP00307512Medicare PIN