Provider Demographics
NPI:1114556370
Name:WIDDERS, BOBIE JO (MD)
Entity type:Individual
Prefix:
First Name:BOBIE
Middle Name:JO
Last Name:WIDDERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BOBIE
Other - Middle Name:JO
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2425 DAVE WARD DR STE 401
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8681
Mailing Address - Country:US
Mailing Address - Phone:501-329-3824
Mailing Address - Fax:501-327-2957
Practice Address - Street 1:2425 DAVE WARD DR STE 401
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8681
Practice Address - Country:US
Practice Address - Phone:501-327-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-16783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program