Provider Demographics
NPI:1437194396
Name:WITTENBERG, SUSAN ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELAINE
Last Name:WITTENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 GRAMERCY ST # 400
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1697
Mailing Address - Country:US
Mailing Address - Phone:713-668-6828
Mailing Address - Fax:
Practice Address - Street 1:2855 GRAMERCY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025
Practice Address - Country:US
Practice Address - Phone:713-668-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2501207WX0108X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179164202Medicaid
TX179164202Medicaid