Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | X010530-1 | NY |
NPI | 1336320662 |
---|---|
Provider Name | Daniel S Widenbaum |
First Address | Suffern, NY 10901-4022 |
Second Address | Suffern, NY 10901-4022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2007 |
Last Update Date | 15/11/2007 |