Provider Demographics
NPI:1053434381
Name:WIDMER, LINDA C (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:C
Last Name:WIDMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:C
Other - Last Name:NI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1049 E WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2474
Mailing Address - Country:US
Mailing Address - Phone:630-232-2776
Mailing Address - Fax:630-315-6565
Practice Address - Street 1:1049 E WILSON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2474
Practice Address - Country:US
Practice Address - Phone:630-232-2776
Practice Address - Fax:630-315-6565
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117674208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036117674OtherMEDICAL LICENSE
IL036117674Medicaid
IL920540041OtherMEDICARE PTAN (INDVIDUAL)
IL920540OtherMEDICARE PTAN (GROUP)