Provider Demographics
NPI:1457647570
Name:WITT, CYNTHIA ROSALINE (OD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ROSALINE
Last Name:WITT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 WESTCREEK DR
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-3777
Mailing Address - Country:US
Mailing Address - Phone:407-952-0558
Mailing Address - Fax:
Practice Address - Street 1:6014 AZLE AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135
Practice Address - Country:US
Practice Address - Phone:817-741-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8157-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist