Provider Demographics
NPI:1679666051
Name:WITKOWSKY, ROMAN B (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:B
Last Name:WITKOWSKY
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 1:512 ENGEL BLVD
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4459
Mailing Address - Country:US
Mailing Address - Phone:847-318-6920
Mailing Address - Fax:
Practice Address - Street 1:512 ENGEL BLVD
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4459
Practice Address - Country:US
Practice Address - Phone:847-318-6920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19603207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30659500Medicaid
WI05090-0646Medicare PIN
WI30659500Medicaid
WI20270-0523Medicare PIN
WI0192-72200Medicare PIN