Provider Demographics
NPI:1205845070
Name:WITTENBERG, BRIAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:WITTENBERG
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:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-0430
Mailing Address - Country:US
Mailing Address - Phone:231-347-5155
Mailing Address - Fax:231-347-6128
Practice Address - Street 1:4048 CEDAR BLUFF DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8895
Practice Address - Country:US
Practice Address - Phone:231-347-5155
Practice Address - Fax:231-347-6128
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054711207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI307797710Medicaid
MI307797710Medicaid
MIF85552Medicare UPIN