Basic Information
| Provider Information | |||||||||
| NPI: | 1780973941 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDAU | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | ALTHEA RENNER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10330 N MERIDIAN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462901024 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8111 TOWNSHIP LINE RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174157921 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2011 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 02004491A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.