Provider Demographics
NPI:1184679516
Name:WITSKEN, MATTHEW GERALD (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GERALD
Last Name:WITSKEN
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 1:5525 MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248-3230
Mailing Address - Country:US
Mailing Address - Phone:513-981-5463
Mailing Address - Fax:513-598-2242
Practice Address - Street 1:5525 MARIE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-3230
Practice Address - Country:US
Practice Address - Phone:513-981-5463
Practice Address - Fax:513-598-2242
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075185W207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00905078OtherMEDICARE RR
OHH14673Medicare UPIN
OH4238592Medicare PIN