Provider Demographics
NPI:1770548554
Name:WIDMAIER, RANDALL SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:SCOTT
Last Name:WIDMAIER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 N 40TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2158
Mailing Address - Country:US
Mailing Address - Phone:602-954-6200
Mailing Address - Fax:602-956-1582
Practice Address - Street 1:5080 N 40TH ST STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2158
Practice Address - Country:US
Practice Address - Phone:602-954-6200
Practice Address - Fax:602-956-1582
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4220111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1Z3082OtherHEALTHNET
AZAZ0245320OtherBLUE CROSS/BLUE SHIELD
AZ818677OtherAPIPA
AZ426305 55Medicaid
AZ4268552OtherAETNA
AZ0628191OtherAETNA HMO
AZ818677OtherAPIPA
AZAZ0245320OtherBLUE CROSS/BLUE SHIELD