Basic Information
| Provider Information | |||||||||
| NPI: | 1629048079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDMER | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | PO BOX 2090 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309960347 | ||||||||
| FaxNumber: | 3309960359 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 S MAIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RITTMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442701914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309253857 | ||||||||
| FaxNumber: | 3309254016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-07-1171-W | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2076999 | 05 | OH | MEDICAID |