Provider Demographics
NPI:1982652319
Name:WIDESKA, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:WIDESKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4816
Mailing Address - Country:US
Mailing Address - Phone:516-222-8688
Mailing Address - Fax:516-745-5476
Practice Address - Street 1:975 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4816
Practice Address - Country:US
Practice Address - Phone:516-222-8688
Practice Address - Fax:516-745-5476
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143739207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01710109Medicaid
NYB10734Medicare UPIN
NY01710109Medicaid