Provider Demographics
NPI:1093826802
Name:WITTENAUER, JAMES ALBERT (DC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALBERT
Last Name:WITTENAUER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1141
Mailing Address - Country:US
Mailing Address - Phone:618-357-5012
Mailing Address - Fax:618-357-9034
Practice Address - Street 1:103 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1141
Practice Address - Country:US
Practice Address - Phone:618-357-5012
Practice Address - Fax:618-357-9034
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-007782111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038007782Medicaid
IL038007782Medicaid