Provider Demographics
NPI:1730107525
Name:WIDLUS, DAVID MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:WIDLUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2207 SHADED BROOK DR
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-2347
Mailing Address - Country:US
Mailing Address - Phone:410-554-2590
Mailing Address - Fax:410-554-2643
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:ROOM N2E16
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5656
Practice Address - Fax:410-328-2115
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00350012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD561371000Medicaid
MDH380J857Medicare PIN
MDJ857Medicare ID - Type UnspecifiedMEDICARE IPIN
MD561371000Medicaid