Provider Demographics
NPI:1457538415
Name:S. GAYLE WIDYOLAR, M.D., INC.
Entity Type:Organization
Organization Name:S. GAYLE WIDYOLAR, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:WIDYOLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-760-2552
Mailing Address - Street 1:21 MONTECITO DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1017
Mailing Address - Country:US
Mailing Address - Phone:949-760-2552
Mailing Address - Fax:949-706-3808
Practice Address - Street 1:21 MONTECITO DR
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1017
Practice Address - Country:US
Practice Address - Phone:949-760-2552
Practice Address - Fax:949-706-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G250560Medicaid
CAG25056Medicare PIN
CA00G250560Medicaid