Provider Demographics
NPI:1437159118
Name:WITTEN, BOBBY D (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:D
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:
Practice Address - Street 1:10188 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2906
Practice Address - Country:US
Practice Address - Phone:336-802-2070
Practice Address - Fax:336-802-2071
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2023-11-29
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
TXK9704207Q00000X
NC2014-01181208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092429202Medicaid
TX092429201Medicaid
TX0064EJOtherBCBS
TX00374LMedicare ID - Type Unspecified
TXH11869Medicare UPIN