Healthcare Provider Details

I. General information

NPI: 1730107525
Provider Name (Legal Business Name): DAVID MICHAEL WIDLUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST ROOM N2E16
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

2207 SHADED BROOK DR
OWINGS MILLS MD
21117-2347
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-5656
  • Fax: 410-328-2115
Mailing address:
  • Phone: 410-554-2590
  • Fax: 410-554-2643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0035001
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: