Provider Demographics
NPI:1114911815
Name:WITTMANN, ERIC KARL (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:KARL
Last Name:WITTMANN
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 1:107 WYNDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:PA
Mailing Address - Zip Code:18414-9546
Mailing Address - Country:US
Mailing Address - Phone:570-563-8594
Mailing Address - Fax:
Practice Address - Street 1:CLARKS SUMMIT STATE HOSPITAL
Practice Address - Street 2:1451 HILLSIDE DR
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411
Practice Address - Country:US
Practice Address - Phone:570-586-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042397E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC34842Medicare UPIN