Provider Demographics
NPI:1477557031
Name:WITTINGEN, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WITTINGEN
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 1:555 MIDTOWNE ST NE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-391-3315
Mailing Address - Fax:616-391-3320
Practice Address - Street 1:555 MIDTOWNE ST NE
Practice Address - Street 2:SUITE 302
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-391-3315
Practice Address - Fax:616-391-3320
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036869207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4736467Medicaid
MI4736467Medicaid
MIOM74460001Medicare ID - Type Unspecified