Healthcare Provider Details

I. General information

NPI: 1932280203
Provider Name (Legal Business Name): VICKY DIANN WIDEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 BAILEY AVE
BUFFALO NY
14215-2814
US

IV. Provider business mailing address

3020 BAILEY AVE
BUFFALO NY
14215-2814
US

V. Phone/Fax

Practice location:
  • Phone: 716-833-3622
  • Fax: 716-834-4557
Mailing address:
  • Phone: 716-833-3622
  • Fax: 716-834-4557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number101YA0400X
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: