Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 15792 | MD |
NPI | 1003083874 |
---|---|
Provider Name | Mrs. Tory Custis Widdowson IV |
First Address | Crisfield, MD 21817-1237 |
Second Address | Crisfield, MD 21817-1237 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2008 |
Last Update Date | 12/05/2008 |