NPIMap

Individual provider Active NPI

David Widjaja, MD

  • Gastroenterology Physician
  • Bronx, NY
National Provider Identifier
1194985291
Registry record updated May 14, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Gastroenterology PhysicianTaxonomy code 207RG0100X
License
275018 Issued in NY
Practice address
1650 Grand Concourse
Bronx, NY 10457-7606
Phone
(718) 960-1234
NPI assigned
Jun 11, 2008
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 14, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Gastroenterology Physician 207RG0100X 275018 NY Primary
Geriatric Medicine (Internal Medicine) Physician 207RG0300X 275018 NY
Internal Medicine Physician 207R00000X 275018 NY

Addresses

Primary practice location

1650 Grand Concourse
Bronx, NY 10457-7606

Mailing address

1650 Selwyn Ave
10TH Floor
Bronx, NY 10457-7626
Phone (718) 960-1234

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY, ND2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20080909000378 NY Practitioner - GastroenterologyPractitioner - Internal MedicinePractitioner - Geriatric Medicine 7315013703 Reassigns benefits to 1 organization
I20180920002035 ND Practitioner - Gastroenterology 7315013703 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Gastroenterology
Education
Other, 1996
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Innovis Health LLCGroup PAC ID 9931298155, 561 clinicians
Albany Medical CollegeGroup PAC ID 1759293111, 1,054 clinicians

Practice addresses (Care Compare)

3000 32ND Ave S
Fargo, ND 58103-6132
Phone (701) 364-8000

47 New Scotland Ave
Albany, NY 12208-3412
Phone (518) 262-5633

Hospital & facility affiliations

  • Albany Medical Center Hospital Hospital, Albany, NY, CCN 330013
  • Essentia Health Hospital, Fargo, ND, CCN 350070

Procedures performed for Medicare patients

ProcedureNumber of procedures
Colonoscopy19
Upper gastrointestinal (GI) endoscopy for acid reflux31

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
275018NYMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Innovis Health LLC CurrentSince Aug 15, 2018 Accepting new patients
Albany Medical College CurrentSince Oct 3, 2016 Accepting new patients
Albany Medical College Internal Medicine Current Accepting new patients
Innovis Health LLC CurrentSince Aug 15, 2018 Accepting new patients
Innovis Health, LLC Current Accepting new patients
Albany Medical College Gastroenterology CurrentSince Oct 3, 2016 Accepting new patients
Albany Medical College Internal Medicine CurrentSince Apr 22, 2022 Accepting new patients

Locations

3000 32nd Ave S
Fargo, ND 58103
Phone (701) 364-3000

1702 University Dr S
Fargo, ND 58103
Phone (701) 364-4222

47 New Scotland Ave
#61
Albany, NY 12208
Phone (518) 262-5791

47 New Scotland Ave
Albany, NY 12208
Phone (518) 262-3773

1275 Broadway
Menands, NY 12204
Phone (518) 262-9705

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1213142400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1400025600000",
    "number": "1194985291",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1650 SELWYN AVE",
            "address_2": "10TH FLOOR",
            "city": "BRONX",
            "state": "NY",
            "postal_code": "104577626",
            "telephone_number": "718-960-1234"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1650 GRAND CONCOURSE",
            "city": "BRONX",
            "state": "NY",
            "postal_code": "104577606",
            "telephone_number": "718-960-1234"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIDJAJA",
        "first_name": "DAVID",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-06-11",
        "last_updated": "2014-05-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RG0100X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Gastroenterology",
            "state": "NY",
            "license": "275018",
            "primary": true
        },
        {
            "code": "207RG0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Geriatric Medicine",
            "state": "NY",
            "license": "275018",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NY",
            "license": "275018",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bronx, NY

Sources for this page

Verify at the official NPI Registry.