Provider Demographics
NPI:1093782427
Name:WITT, MARK A (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WITT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-232-8501
Mailing Address - Fax:903-232-8226
Practice Address - Street 1:709 HOLLYBROOK DR
Practice Address - Street 2:SUITE 3401
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2411
Practice Address - Country:US
Practice Address - Phone:903-753-1778
Practice Address - Fax:903-753-7202
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1692213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00442444OtherRR MEDICARE
TX166961601Medicaid
TXV00866Medicare UPIN
TX166961601Medicaid