Provider Demographics
NPI:1447360615
Name:WIDER, JERRY A (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:WIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WATERVILLE RD
Mailing Address - Street 2:WHNY MANAGED CARE
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2066
Mailing Address - Country:US
Mailing Address - Phone:860-676-7421
Mailing Address - Fax:
Practice Address - Street 1:48 ROUTE 25A
Practice Address - Street 2:SUITE 207
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1431
Practice Address - Country:US
Practice Address - Phone:631-862-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092304207V00000X, 207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Not Answered207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Not Answered207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics