Healthcare Provider Details

I. General information

NPI: 1790756443
Provider Name (Legal Business Name): MARNIE JEAN WIDDIFIELD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARNIE JEAN DORNHECKER MD

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1542 S BLOOMINGTON ST
GREENCASTLE IN
46135-2297
US

IV. Provider business mailing address

549 E COUNTY LINE RD SUITE A
GREENWOOD IN
46143-1067
US

V. Phone/Fax

Practice location:
  • Phone: 765-301-7617
  • Fax: 765-301-7621
Mailing address:
  • Phone: 317-497-6180
  • Fax: 317-497-6184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01051575A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: