Widstrom, Mark Kenneth

Widstrom, Mark Kenneth is an individual health care provider with primary practice located at 400 E 3Rd St , Duluth MN 55805-1951. He recently has only one registered license in Allopathic & Osteopathic Physicians / Obstetrics & Gynecology, which is considered as his primary health care specialty. Widstrom, Mark Kenneth can be contacted via phone (218) 786-8364.

Contact Information

Primary practice address
400 E 3Rd St Duluth MN 55805-1951
Phone: (218) 786-8364
Fax:
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Obstetrics & Gynecology 207V00000X 45497 Minnesota

Profile Details

NPI number 1689692758
LBN Legal business name Widstrom, Mark Kenneth
Credentials
Entity Individual
Sole proprietor 1 No
Enumeration date Jul 17th, 2006
Last updated May 9th, 2011 - about 14 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1689692758 NPPES
Wisconsin MEDICAID 34348400
Wisconsin MEDICAID 542440200

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