Provider Demographics
NPI:1932835238
Name:WIDEMAN, ANTONIO JAMAAL (PEER SPECIALIST)
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:JAMAAL
Last Name:WIDEMAN
Suffix:
Gender:M
Credentials:PEER SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:884 CUMMINS HWY APT 4
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2043
Mailing Address - Country:US
Mailing Address - Phone:617-691-6034
Mailing Address - Fax:
Practice Address - Street 1:884 CUMMINS HWY APT 4
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2043
Practice Address - Country:US
Practice Address - Phone:617-691-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202222175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty