Provider Demographics
NPI:1629044797
Name:WITKOVSKY, MICHAEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:WITKOVSKY
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 1:301 W TROY
Mailing Address - Street 2:MENDOTA MENTAL HEALTH INSTITUTE
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1187
Mailing Address - Country:US
Mailing Address - Phone:608-301-1075
Mailing Address - Fax:608-226-5429
Practice Address - Street 1:301 TROY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1521
Practice Address - Country:US
Practice Address - Phone:608-301-1075
Practice Address - Fax:608-226-5429
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI324002084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31769600Medicaid
WI31769600Medicaid
F13242Medicare UPIN