MEDICARE: DR. ELISABETH REGINA WIDMAN 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	207Q00000X	Family Medicine Physician	G46518	CA

General Provider Information

NPI Number	:	1831173855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISABETH REGINA WIDMAN MD

Provider Business Mailing Address
First Line	:	706 D ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-3757
Country	:	US
Telephone Number	:	415-256-1980
Fax Number	:	415-256-1981

Provider Business Practice Location Address
First Line	:	706 D ST
Second Line	:	E REGINA WIDMAN MD
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-3757
Country	:	US
Telephone Number	:	415-256-1980
Fax Number	:	415-256-1981

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	07/08/2007

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