Provider Demographics
NPI:1942341417
Name:WIDROW, ROBERT JON (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JON
Last Name:WIDROW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:525 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5101
Mailing Address - Country:US
Mailing Address - Phone:360-493-5360
Mailing Address - Fax:360-493-5511
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5101
Practice Address - Country:US
Practice Address - Phone:360-493-4410
Practice Address - Fax:360-493-5511
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA00042221207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH89761Medicare UPIN