Provider Demographics
NPI:1376553644
Name:WITTENBERG, STEPHEN W (DPMPC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:W
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:DPMPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28037 DEQUINDRE
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071
Mailing Address - Country:US
Mailing Address - Phone:248-542-7500
Mailing Address - Fax:248-542-7502
Practice Address - Street 1:28037 DEQUINDRE
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071
Practice Address - Country:US
Practice Address - Phone:248-542-7500
Practice Address - Fax:248-542-7502
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000585213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
563530634Medicare ID - Type Unspecified
T34178Medicare UPIN