Provider Demographics
NPI:1588649826
Name:WITTENBERG, ALAN L (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:WITTENBERG
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 1:17929 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-1221
Mailing Address - Country:US
Mailing Address - Phone:216-481-1890
Mailing Address - Fax:216-481-1892
Practice Address - Street 1:17929 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1221
Practice Address - Country:US
Practice Address - Phone:216-481-1890
Practice Address - Fax:216-481-1892
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO815213ES0103X
OH36.001518213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0150492Medicaid
OHT80363Medicare UPIN
OH0460200001Medicare NSC
OHWI0361771Medicare ID - Type Unspecified