Provider Demographics
NPI:1073523098
Name:WITT, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:WITT
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 1:7230 ENGLE ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2209
Mailing Address - Country:US
Mailing Address - Phone:260-234-5400
Mailing Address - Fax:260-234-5400
Practice Address - Street 1:280 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IN
Practice Address - Zip Code:46783-1045
Practice Address - Country:US
Practice Address - Phone:260-672-9285
Practice Address - Fax:260-672-3537
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035243A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100257170Medicaid
INM400019359Medicare PIN
INM400052465Medicare PIN
IN100257170Medicaid