Provider Demographics
NPI:1336255728
Name:WIDEMAN, JOHN GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GRANT
Last Name:WIDEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:503 CLARK ST NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-1921
Mailing Address - Country:US
Mailing Address - Phone:256-739-0801
Mailing Address - Fax:256-739-0027
Practice Address - Street 1:1800 AL HIGHWAY 157 STE 302
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-1273
Practice Address - Country:US
Practice Address - Phone:256-736-6224
Practice Address - Fax:256-736-6226
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL22380207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL117937Medicaid
AL118948Medicaid
AL051558102Medicare ID - Type Unspecified