Provider Demographics
NPI:1568922979
Name:WITYK, ELLIOTT (DPM)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:WITYK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5011
Mailing Address - Country:US
Mailing Address - Phone:817-540-4477
Mailing Address - Fax:817-540-5633
Practice Address - Street 1:520 SAMUELS AVE APT 3310
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-8613
Practice Address - Country:US
Practice Address - Phone:417-839-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX3132213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist