Justin Wade Widner, DO

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

3903 Issued in TN

Practice address

1610 Tazewell Rd Ste 203
Tazewell, TN 37879-3648

Phone

(423) 259-3701

Fax

(866) 954-5783

NPI assigned

May 25, 2017

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Osteopathy

Practice roles

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.

• East Tennessee Children'S Primary Care Center, Inc.

  • Pediatrics Physician
  • Knoxville, TN
  • NPI 1235350901
  NPD (past)

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

{
    "created_epoch": "1495670400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1649376000000",
    "number": "1225566953",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 15004",
            "city": "KNOXVILLE",
            "state": "TN",
            "postal_code": "379015004",
            "telephone_number": "865-541-8895",
            "fax_number": "865-633-4808"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1610 TAZEWELL RD STE 203",
            "city": "TAZEWELL",
            "state": "TN",
            "postal_code": "378793648",
            "telephone_number": "423-259-3701",
            "fax_number": "866-954-5783"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIDNER",
        "first_name": "JUSTIN",
        "middle_name": "WADE",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-05-25",
        "last_updated": "2022-04-08",
        "certification_date": "2022-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "TN",
            "license": "3903",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q042576",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Value RX LLC
• Kyler Vogel, PA-C
• Sunan Vongkasemsiri, M.D.
• Trecinda Wallace, SPEECH PATHOLOGIST
• We Care Physical Therapy LLC
• Robert J Wilmoth, MD
• Women'S Health Center & Primary Care
• Womens Health Center TN
• Lillia Afton Zellers, APRN-C

• Pediatrics Physician in Tazewell, TN
• Providers in Tazewell, TN by specialty
• Pediatrics Physician in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.