Jack Garrett Widman, DO

Primary specialty

Emergency Medicine PhysicianTaxonomy code 207P00000X

License

DO4212 Issued in NV

Practice address

4700 Las Vegas Blvd N
Nellis Afb, NV 89191-6600

Phone

(702) 653-2273

NPI assigned

May 19, 2023

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in AZ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

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

{
    "created_epoch": "1684454400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1788825600000",
    "number": "1306537279",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4700 LAS VEGAS BLVD N",
            "city": "NELLIS AFB",
            "state": "NV",
            "postal_code": "891916600",
            "telephone_number": "702-653-2273"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4700 LAS VEGAS BLVD N",
            "city": "NELLIS AFB",
            "state": "NV",
            "postal_code": "891916600",
            "telephone_number": "702-653-2273"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIDMAN",
        "first_name": "JACK",
        "middle_name": "GARRETT",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2023-05-19",
        "last_updated": "2026-09-08",
        "certification_date": "2026-09-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Emergency Medicine",
            "state": "NV",
            "license": "DO4212",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Teresa Whetstone, MD
• Bryan Matthew White, M.D.
• Codie James White, 'IDMT'
• Rahsaan White, PROPHY TECH
• Derric A. Whiteside, D.O.
• Leah M Williams, FNP
• Ryan Williams, PA-C
• Shanita Williams, NP
• Kara Wilson, RD
• Dana Windhorst, MD

• Emergency Medicine Physician in Nellis Afb, NV
• Providers in Nellis Afb, NV by specialty
• Emergency Medicine Physician in Nevada

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.