MEDICARE: DR. ELYSA WIDJAJA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085P0229X	Pediatric Radiology Physician	036.161747	IL
2	2085R0202X	Diagnostic Radiology Physician	036161747	IL
3	2085P0229X	Pediatric Radiology Physician	35.155182	OH

General Provider Information

NPI Number	:	1184331522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELYSA WIDJAJA MD

Provider Business Mailing Address
First Line	:	3333 BURNET AVE
Second Line	:	ML 5031
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3026
Country	:	US
Telephone Number	:	513-636-4251
Fax Number	:	513-636-8145

Provider Business Practice Location Address
First Line	:	3333 BURNET AVE
Second Line	:	ML 5031
City	:	CINCINNATI
State	:	OH
Zip	:	45229-3026
Country	:	US
Telephone Number	:	513-636-4251
Fax Number	:	513-636-8145

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2022
Last Update Date	:	02/12/2026

Similar Medicare Providers

1598273419 — PATRICIA ANN HAAS APRN-CNP
Practice Location Address:

3333 BURNET AVENUE , MLC 3014
CINCINNATI, OH
45229-3026

Practice Phone: 513-636-4788
Practice Fax: 513-636-4283

1255948329 — JOEL EMILIO DIAZ-PORTORREAL
Practice Location Address:

3333 BURNET AVE
CINCINNATI, OH
45229-3026

Practice Phone: 513-636-4200
Practice Fax:

1356994867 — HEIDY COROMOTO MARTINEZ MD
Practice Location Address:

3333 BURNET AVE
CINCINNATI, OH
45229-3026

Practice Phone: 513-636-4751
Practice Fax: 513-636-7911

1437653607 — JEREMY BRIAN SHAPIRO MD
Practice Location Address:

3333 BURNET AVENUE , MLC 5018
CINCINNATI, OH
45229-3026

Practice Phone: 513-636-4315
Practice Fax:

1285363580 — ANNA ANDERSON
Practice Location Address:

3333 BURNET AVE
CINCINNATI, OH
45229-3026

Practice Phone: 513-636-4200
Practice Fax:

1255070561 — SIDNEY KIEFABER
Practice Location Address:

3333 BURNET AVE
CINCINNATI, OH
45229-3026

Practice Phone: 513-636-0800
Practice Fax: 513-803-0823

Directions to “ DR. ELYSA WIDJAJA MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.