Basic Information
| Provider Information | |||||||||
| NPI: | 1982632998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIDLUND | ||||||||
| FirstName: | BENGT | ||||||||
| MiddleName: | OLOV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1721 HOLBROOK AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982031623 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1321 COLBY AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252583678 | ||||||||
| FaxNumber: | 4252583048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207L00000X | MD00021686 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1010511 | 05 | WA | MEDICAID | 189645 | 01 | L&I | OTHER | 0712WI | 01 | D/S REGENCE 90 | OTHER |