Provider Demographics
NPI:1568793107
Name:WITTERT, JERROLD STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:STEVEN
Last Name:WITTERT
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 1:4462 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-1807
Mailing Address - Country:US
Mailing Address - Phone:510-537-5533
Mailing Address - Fax:415-861-6530
Practice Address - Street 1:4462 17TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1807
Practice Address - Country:US
Practice Address - Phone:510-537-5533
Practice Address - Fax:415-861-6530
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G263171Medicare PIN