Provider Demographics
NPI:1720101504
Name:WIDLAN, SHELDON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:
Last Name:WIDLAN
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 1:1100 LIGONIER STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650
Mailing Address - Country:US
Mailing Address - Phone:704-539-8517
Mailing Address - Fax:412-241-4325
Practice Address - Street 1:1100 LIGONIER STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650
Practice Address - Country:US
Practice Address - Phone:704-539-8517
Practice Address - Fax:412-241-4325
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019695E207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA63633Medicaid
B34447Medicare UPIN
PA63633Medicaid