Healthcare Provider Details

I. General information

NPI: 1114554995
Provider Name (Legal Business Name): JOHN CHRISTIAN WIDERE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
MORGANTOWN WV
26506-1200
US

IV. Provider business mailing address

1215 LEE ST. BOX 800744
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 434-924-1931
  • Fax: 434-243-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number36719
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36719
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD495209
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD495209
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: