Provider Demographics
NPI:1790756443
Name:WIDDIFIELD, MARNIE JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARNIE
Middle Name:JEAN
Last Name:WIDDIFIELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:MARNIE
Other - Middle Name:JEAN
Other - Last Name:DORNHECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:549 E COUNTY LINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1067
Mailing Address - Country:US
Mailing Address - Phone:317-497-6180
Mailing Address - Fax:317-497-6184
Practice Address - Street 1:1542 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2297
Practice Address - Country:US
Practice Address - Phone:765-301-7617
Practice Address - Fax:765-301-7621
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051575A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN510512209OtherPROHEALTH
IN510512209OtherOPEN
IN000000001373OtherMPLAN (PROHEALTH)
INP00201816OtherRR MEDICARE
IN510512209OtherCOMMERCIAL INSURANCE
IN000000336833OtherBLUE CROSS / BLUE SHIELD
IN510512209OtherPROHEALTH
IN510512209OtherOPEN