Provider Demographics
NPI:1447576145
Name:CHARLES B. WITT, JR MD INC
Entity Type:Organization
Organization Name:CHARLES B. WITT, JR MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:WITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:323-466-7333
Mailing Address - Street 1:316 NORTH ROSSMORE AVENUE
Mailing Address - Street 2:SUITE 507
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-2415
Mailing Address - Country:US
Mailing Address - Phone:323-466-7333
Mailing Address - Fax:323-871-1696
Practice Address - Street 1:316 NORTH ROSSMORE AVENUE
Practice Address - Street 2:SUITE 507
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-2415
Practice Address - Country:US
Practice Address - Phone:323-466-7333
Practice Address - Fax:323-871-1696
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLES B. WITT, JR MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG3366208600000X, 208D00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G33660Medicaid
CA000G33660Medicaid