Healthcare Provider Details

I. General information

NPI: 1083817373
Provider Name (Legal Business Name): JD WIDEMAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 09/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3519 RICHMOND DR
FORT COLLINS CO
80526-5995
US

IV. Provider business mailing address

3702 AUTOMATION WAY SUITE 103
FORT COLLINS CO
80525-5737
US

V. Phone/Fax

Practice location:
  • Phone: 970-204-0300
  • Fax: 970-221-5206
Mailing address:
  • Phone: 970-224-1670
  • Fax: 970-495-6218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47085
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: