Provider Demographics
NPI:1326007303
Name:WITTPENN, GREGORY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
Last Name:WITTPENN
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 1:3616 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2539
Mailing Address - Country:US
Mailing Address - Phone:936-564-3744
Mailing Address - Fax:936-564-0642
Practice Address - Street 1:3616 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2539
Practice Address - Country:US
Practice Address - Phone:936-564-3744
Practice Address - Fax:936-564-0642
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH88962082S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4470780OtherAETNA PIN
TX0070LYOtherBLUE CROSS PROVIDER #
TX3324976OtherREDILINK BLUE #
TX173185301Medicaid
TX00258YMedicare ID - Type Unspecified
TX4470780OtherAETNA PIN
TX8D2010Medicare PIN