Provider Demographics
NPI:1093819377
Name:WITZENFELD, JACK T (PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:T
Last Name:WITZENFELD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 BONNEY RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3869
Mailing Address - Country:US
Mailing Address - Phone:757-490-9388
Mailing Address - Fax:757-490-9401
Practice Address - Street 1:736 BATTLEFIELD BLVD N
Practice Address - Street 2:CHESAPEAKE GENERAL HOSPITAL
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4941
Practice Address - Country:US
Practice Address - Phone:757-490-9388
Practice Address - Fax:757-490-9401
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840299363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
970000664OtherMEDICARE RAILROAD
970000664OtherMEDICARE RAILROAD
970000572Medicare ID - Type Unspecified