Provider Demographics
NPI:1255319877
Name:WITT, PETER C (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:C
Last Name:WITT
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 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:630 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6113
Practice Address - Country:US
Practice Address - Phone:505-609-6349
Practice Address - Fax:505-599-4679
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49164207RG0100X
CO34642207RG0100X
NMMD2015-0843207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1255319877Medicaid
CO01346428Medicaid
NM1J2390Medicaid
NE10025926100Medicaid
COP00944654OtherMEDICARE RAILROAD CARRIER PTAN
COA97649Medicare UPIN
NE10025926100Medicaid