Provider Demographics
NPI:1922010800
Name:WIDMANN, CLARENCE LOUIS (OD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:LOUIS
Last Name:WIDMANN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 WESTVIEW VLG
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5234
Mailing Address - Country:US
Mailing Address - Phone:254-776-3937
Mailing Address - Fax:254-776-6810
Practice Address - Street 1:533 WESTVIEW VLG
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5234
Practice Address - Country:US
Practice Address - Phone:254-776-3937
Practice Address - Fax:254-776-6810
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3751TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093402802Medicaid
T16615Medicare UPIN
TX093402802Medicaid