Provider Demographics
NPI:1104088566
Name:WIDENER, DOUGLAS B (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:B
Last Name:WIDENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 HICKORY FLAT HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4229
Mailing Address - Country:US
Mailing Address - Phone:678-505-4455
Mailing Address - Fax:
Practice Address - Street 1:1495 HICKORY FLAT HWY STE 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-4229
Practice Address - Country:US
Practice Address - Phone:678-505-4455
Practice Address - Fax:678-505-4446
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063452207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program