Courtney Yung Widjaja, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

92344 Issued in GA

Practice address

595 Hurricane Shoals Road NW
Suite 300
Lawrenceville, GA 30046

Phone

(770) 995-0823

Fax

(770) 995-7018

NPI assigned

Apr 16, 2019

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

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 Medicine

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: courtney.widjaja.1@14859.direct.athenahealth.com
• FHIR API: https://api.platform.athenahealth.com/14859/brand/1/csg/1/fhir/r4

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.

• Gwinnett Pediatrics & Adolescent Medicine

  • Pediatrics Physician
  • Lawrenceville, GA
  • NPI 1003940909
  NPD (past)

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

{
    "created_epoch": "1555372800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1663891200000",
    "number": "1356904379",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "595 HURRICANE SHOALS ROAD NW",
            "address_2": "SUITE 300",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "30046",
            "telephone_number": "770-995-0823",
            "fax_number": "770-995-7018"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "595 HURRICANE SHOALS ROAD NW",
            "address_2": "SUITE 300",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "30046",
            "telephone_number": "770-995-0823",
            "fax_number": "770-995-7018"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIDJAJA",
        "first_name": "COURTNEY",
        "middle_name": "YUNG",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-04-16",
        "last_updated": "2022-09-23",
        "certification_date": "2022-09-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "10825",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "92344",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Leigh Evans Whitton, D.P.T.
• Whole Life Health Center LLC (Pain Center of Gwinnett)
• Wholehearted Healing Counseling LLC
• Wholeness Counseling & Coaching LLC
• Anna Wicks
• Jani Widjaja, MD
• Raegan Wieder
• Hanz E Wien, DPT
• Jonathan Wiesner, CAC II
• Andronica Wiggins, NP

• Pediatrics Physician in Lawrenceville, GA
• Providers in Lawrenceville, GA by specialty
• Pediatrics Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2022; 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.