Provider Demographics
NPI:1679678775
Name:WITZKE, STEPHEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:WITZKE
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:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-6253
Mailing Address - Fax:517-364-6204
Practice Address - Street 1:230 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-1837
Practice Address - Country:US
Practice Address - Phone:517-676-9066
Practice Address - Fax:517-676-3505
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0803306661OtherBCBS INDIVIDUAL PIN
MI4327090Medicaid
MI200000001051OtherPHP PIN #
MIH45877Medicare UPIN
MIN18300005Medicare PIN