Provider Demographics
NPI:1659366052
Name:WITKOWSKI, MARK T (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:WITKOWSKI
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 1:709 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1823
Mailing Address - Country:US
Mailing Address - Phone:304-265-4131
Mailing Address - Fax:304-265-6443
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1283
Practice Address - Country:US
Practice Address - Phone:304-265-7406
Practice Address - Fax:304-265-6443
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053404000Medicaid
WV080104463Medicare PIN
WV0053404000Medicaid
WV2017651Medicare PIN