MEDICARE: DR. JONATHAN WIDEROFF M.D.

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	174400000X	Specialist	ME35997	FL
2	208600000X	Surgery Physician	ME35997	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215925367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN WIDEROFF M.D.

Provider Business Mailing Address
First Line	:	1601 CLINT MOORE RD
Second Line	:	SUITE 145
City	:	BOCA RATON
State	:	FL
Zip	:	33487-2768
Country	:	US
Telephone Number	:	561-939-0455
Fax Number	:	561-939-5460

Provider Business Practice Location Address
First Line	:	1601 CLINT MOORE RD STE 145
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33487-5720
Country	:	US
Telephone Number	:	561-288-2537
Fax Number	:	561-939-5460

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	09/24/2020

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