Provider Demographics
NPI:1386656577
Name:WITTER, THEODORE OSWALD (MD)
Entity Type:Individual
Prefix:MS
First Name:THEODORE
Middle Name:OSWALD
Last Name:WITTER
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 1:17 SYLVAN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2069
Mailing Address - Country:US
Mailing Address - Phone:201-438-2824
Mailing Address - Fax:201-438-2108
Practice Address - Street 1:17 SYLVAN ST STE 201
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-2069
Practice Address - Country:US
Practice Address - Phone:201-438-2824
Practice Address - Fax:201-438-2108
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA051466174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0777901Medicaid
NJA61129Medicare UPIN
NJ0777901Medicaid