Provider Demographics
NPI:1235432568
Name:WITSMAN, CLINTON MATTHEW (DPT)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:MATTHEW
Last Name:WITSMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1504 PATTON DR
Practice Address - Street 2:UNIT 4
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8126
Practice Address - Country:US
Practice Address - Phone:217-590-0340
Practice Address - Fax:217-590-0342
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid