Provider Demographics
NPI:1285636589
Name:WITTLER, MARK A (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WITTLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-5009
Mailing Address - Country:US
Mailing Address - Phone:308-635-3001
Mailing Address - Fax:308-635-3001
Practice Address - Street 1:921 W 36TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-5009
Practice Address - Country:US
Practice Address - Phone:308-635-3001
Practice Address - Fax:308-633-1308
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09694OtherBC/BS
NE47073455800Medicaid
NE09694OtherBC/BS