Provider Demographics
NPI:1144220641
Name:WITTBERG, KATHLEEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:R
Last Name:WITTBERG
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Gender:F
Credentials:MD
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Mailing Address - Street 1:9000 NORTH MAIN ST
Mailing Address - Street 2:SUITE 403 MAIN STREET FAMILY PRACTICE INC
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-836-1572
Mailing Address - Fax:937-832-0728
Practice Address - Street 1:9000 NORTH MAIN ST
Practice Address - Street 2:MAIN STREET FAMILY PRACTICE INC SUITE 403
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-836-5171
Practice Address - Fax:937-832-0728
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2008-03-24
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Provider Licenses
StateLicense IDTaxonomies
OH35048051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1139935OtherCIGNA
OH000000013668OtherANTHEM DR WITTBERG
OH4328348OtherAETNA DR WITTBERG
OH0534265Medicaid
OH0122424OtherUHC DR WITTBERG
OH0122424OtherUHC DR WITTBERG
OH0742201Medicare PIN