MEDICARE: DR. LAWRENCE W WIDERLITE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	D0006493	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D0006493	OTHER	MD	STATE LICENSE

General Provider Information

NPI Number	:	1750350294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE W WIDERLITE M.D.

Provider Business Mailing Address
First Line	:	12510 PROSPERITY DR
Second Line	:	SUITE 200
City	:	SILVER SPRING
State	:	MD
Zip	:	20904-1663
Country	:	US
Telephone Number	:	240-485-5200
Fax Number	:	301-625-6906

Provider Business Practice Location Address
First Line	:	5550 FRIENDSHIP BLVD
Second Line	:	SUITE T-90
City	:	CHEVY CHASE
State	:	MD
Zip	:	20815-7256
Country	:	US
Telephone Number	:	240-737-0085
Fax Number	:	301-654-2986

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/06/2016

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Directions to “ DR. LAWRENCE W WIDERLITE M.D.” Practice Location

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