Healthcare Provider Details

I. General information

NPI: 1851471072
Provider Name (Legal Business Name): DIANA T WIDICUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SATTLEY ST
ROCHESTER IL
62563-9241
US

IV. Provider business mailing address

1836 SOUTH MACARTHUR BLVD
SPRINGFIELD IL
62704
US

V. Phone/Fax

Practice location:
  • Phone: 217-789-3630
  • Fax: 217-498-6812
Mailing address:
  • Phone: 217-789-1403
  • Fax: 217-789-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36062017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: