1255361317 NPI number — DR. MARY A WITTLER MD

Table of content: DR. MARY A WITTLER MD (NPI 1255361317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255361317 NPI number — DR. MARY A WITTLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITTLER
Provider First Name:
MARY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255361317
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 344
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27102-0344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-716-2255
Provider Business Mailing Address Fax Number:
336-716-6543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON-SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27157-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-716-2255
Provider Business Practice Location Address Fax Number:
336-716-5438
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2003-00729 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89134YN , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202780 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".
  • Identifier: N0072A , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 134YN . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3810009143 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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