Basic Information
| Provider Information | |||||||||
| NPI: | 1215557178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIDENER | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 EVERETT DR | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715125 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 N LEE AVE RM 1980 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052728437 | ||||||||
| FaxNumber: | 4052313007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2020 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 0390R | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.