Provider Demographics
NPI:1154326122
Name:WITTPENN, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:WITTPENN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:825 E GATE BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2136
Mailing Address - Country:US
Mailing Address - Phone:516-804-5200
Mailing Address - Fax:516-240-6540
Practice Address - Street 1:4 TECHNOLOGY DR
Practice Address - Street 2:SUITE 150
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4080
Practice Address - Country:US
Practice Address - Phone:631-941-1400
Practice Address - Fax:631-941-1476
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2019-09-18
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Provider Licenses
StateLicense IDTaxonomies
NY174403207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01086933Medicaid
NY01086933Medicaid
NY24E6838262Medicare PIN