Provider Demographics
NPI:1063453736
Name:WITTENBERG, JOHN FREDERICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FREDERICK
Last Name:WITTENBERG
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 1:4001 W 15TH ST
Mailing Address - Street 2:SUITE 245
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5841
Mailing Address - Country:US
Mailing Address - Phone:972-596-5222
Mailing Address - Fax:972-596-5291
Practice Address - Street 1:4001 W 15TH ST
Practice Address - Street 2:SUITE 245
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5841
Practice Address - Country:US
Practice Address - Phone:972-596-5222
Practice Address - Fax:972-596-5291
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099747002Medicaid
TX099747003OtherMEDICAID OTHER
TX110129394OtherRAILROAD MEDICARE
TX110129394OtherRAILROAD MEDICARE
TX88Y125Medicare PIN