Provider Demographics
NPI:1184285249
Name:WIDJAJA, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WIDJAJA
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 1:2151 MEETING ST APT 12209
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4662
Mailing Address - Country:US
Mailing Address - Phone:347-749-8428
Mailing Address - Fax:
Practice Address - Street 1:299 KINGS DAUGHTERS DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-4186
Practice Address - Country:US
Practice Address - Phone:502-875-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine