Provider Demographics
NPI:1215915210
Name:WIDNER, LARRY A (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:WIDNER
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:PO BOX 5007
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-5007
Mailing Address - Country:US
Mailing Address - Phone:336-882-1416
Mailing Address - Fax:336-882-7691
Practice Address - Street 1:624 QUAKER LN
Practice Address - Street 2:SUITE 117-B
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-3832
Practice Address - Country:US
Practice Address - Phone:336-882-1416
Practice Address - Fax:336-882-7691
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28380174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8987271Medicaid
NC87271OtherBCBSNC
NC8987271Medicaid
NCC82421Medicare UPIN