Healthcare Provider Details

I. General information

NPI: 1306085766
Provider Name (Legal Business Name): JEFFREY S. WIDELITZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

6135 PARK SOUTH DR STE 510
CHARLOTTE NC
28210-0100
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2000
  • Fax:
Mailing address:
  • Phone: 704-749-3116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberC10009698
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2018-02919
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: