Provider Demographics
NPI:1164097663
Name:WITTE, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WITTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 JEFFERSON AVE SE
Mailing Address - Street 2:JEFFERSON 305
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-6867
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE # ES-215
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5491
Practice Address - Country:US
Practice Address - Phone:617-667-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43510479012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology