Provider Demographics
NPI:1356904379
Name:WIDJAJA, COURTNEY YUNG (MD)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:YUNG
Last Name:WIDJAJA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 HURRICANE SHOALS ROAD NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:770-995-0823
Mailing Address - Fax:770-995-7018
Practice Address - Street 1:595 HURRICANE SHOALS ROAD NW
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-995-0823
Practice Address - Fax:770-995-7018
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10825208000000X
GA92344208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics