Provider Demographics
NPI:1376518431
Name:WITTEN, CHARLES N (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:N
Last Name:WITTEN
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 1:4106 W LAKE MARY BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3344
Mailing Address - Country:US
Mailing Address - Phone:407-332-7700
Mailing Address - Fax:321-275-0339
Practice Address - Street 1:4106 W LAKE MARY BLVD STE 215
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3344
Practice Address - Country:US
Practice Address - Phone:407-332-7700
Practice Address - Fax:321-275-0339
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057403208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10292OtherBCBS
FL063246500Medicaid
FL340003010OtherMDCR RAILROAD
FL340003010OtherMDCR RAILROAD
FLE60453Medicare UPIN