Provider Demographics
NPI:1568431534
Name:WITTERHOLT, KENNETH A (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:WITTERHOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:915 OLD FERN HILL RD
Mailing Address - Street 2:BUILDING B, SUITE 201
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4269
Mailing Address - Country:US
Mailing Address - Phone:610-436-6696
Mailing Address - Fax:610-430-6023
Practice Address - Street 1:915 OLD FERN HILL RD
Practice Address - Street 2:BUILDING B, SUITE 201
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4269
Practice Address - Country:US
Practice Address - Phone:610-436-6696
Practice Address - Fax:610-430-6023
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044526L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012483500003Medicaid
PA675190M10Medicare ID - Type Unspecified
PA0012483500003Medicaid