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General NPI Number Information
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NPI Number | 1629157003
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Entity Type | Individual
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Provider Name | TODD M WIDER MD
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Gender | Male
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Dates
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Enumeration Date | 11/04/2006
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Last Update Date | 02/18/2009
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Provider Practice Location Address
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Address Line | 871 5TH AVENUE
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City | NEW YORK
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State | NY
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Zip | 10023
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Country | US
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Telephone | 212-772-1229
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Fax | 212-737-8569
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Provider Business Mailing Address
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Address Line | 48 ROUTE 25A 202
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City | SMITHTOWN
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State | NY
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Zip | 11787-1431
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Country | US
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Telephone | 631-862-3625
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Fax | 631-862-3347
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0122X
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Taxonomy Name | Plastic and Reconstructive Surgery Physician
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License Number | 193602
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License Number State | NY
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