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NPI Code Detail

MEDICARE: DR. JANI WIDJAJA MD

MEDICARE: DR. JANI 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
12085R0202XDiagnostic Radiology Physician49221GA

Other Identifiers

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

General Provider Information

NPI Number : 1902881287
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JANI WIDJAJA MD
Provider Business Mailing Address
First Line : PO BOX 1746
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46206-1746
Country : US
Telephone Number : 877-383-4442
Fax Number :
Provider Business Practice Location Address
First Line : 1000 MEDICAL CENTER BLVD
Second Line : RADIOLOGY DEPT
City : LAWRENCEVILLE
State : GA
Zip : 30045-7694
Country : US
Telephone Number : 770-995-4321
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/09/2005
Last Update Date : 04/06/2022

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