Provider Demographics
NPI:1417933953
Name:WITTENAUER, TIMOTHY JAMES
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:WITTENAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WALTON PARK LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-3028
Mailing Address - Country:US
Mailing Address - Phone:804-560-9575
Mailing Address - Fax:804-560-9557
Practice Address - Street 1:108 WALTON PARK LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3028
Practice Address - Country:US
Practice Address - Phone:804-560-9575
Practice Address - Fax:804-560-9557
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4454125OtherAETNA
114481OtherANTHEM
1985263OtherFIRST HEALTH
000003A65Medicare ID - Type Unspecified