Provider Demographics
NPI:1215979703
Name:WIDDOES, KAREN S (PT, MDT)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:WIDDOES
Suffix:
Gender:F
Credentials:PT, MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4102 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4169
Practice Address - Country:US
Practice Address - Phone:302-894-1800
Practice Address - Fax:302-894-1811
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10000289225100000X
PAPT008698E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000038044Medicaid
336345OtherMAMSI
PAPT008698EOtherPA LICENSE
PA0682261000OtherAMERIHEALTH/IBC
DEJ10000289OtherDE LICENSE
0682261000OtherAMERIHEALTH IBC
0682261000OtherAMERIHEALTH IBC
DE1000038044Medicaid
PAPT008698EOtherPA LICENSE