Provider Demographics
NPI:1538100508
Name:WITTICH, KATHLEEN SUE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUE
Last Name:WITTICH
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 1:4189 WESTLAWN S
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1100
Mailing Address - Country:US
Mailing Address - Phone:319-335-8392
Mailing Address - Fax:319-335-7247
Practice Address - Street 1:4189 WESTLAWN S
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1100
Practice Address - Country:US
Practice Address - Phone:319-335-8392
Practice Address - Fax:319-335-7247
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098826207Q00000X
IA31914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4141325Medicaid
IA23364OtherWELLMARK BCBS
G39636Medicare UPIN
ILK19106 / 211972Medicare ID - Type Unspecified
IA23364OtherWELLMARK BCBS