Provider Demographics
NPI:1275863243
Name:JOHN T. WITTE, M.D., P.A.
Entity Type:Organization
Organization Name:JOHN T. WITTE, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WITTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-343-6458
Mailing Address - Street 1:425 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6035
Mailing Address - Country:US
Mailing Address - Phone:208-343-1702
Mailing Address - Fax:208-342-7042
Practice Address - Street 1:2235 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8026
Practice Address - Country:US
Practice Address - Phone:208-887-3724
Practice Address - Fax:208-887-1682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5529207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002733600Medicaid
1122028Medicare PIN