Provider Demographics
NPI:1700868643
Name:WITTENBERG, LEE A (DPM)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:A
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 1:2901 N TENAYA WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1404
Mailing Address - Country:US
Mailing Address - Phone:702-362-2622
Mailing Address - Fax:702-362-0422
Practice Address - Street 1:2901 N TENAYA WAY STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1404
Practice Address - Country:US
Practice Address - Phone:702-362-2622
Practice Address - Fax:702-362-0422
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2301213ES0103X
FLPO2949213ES0103X
NV0607213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
042472266OtherONE HEALTH PLAN
7126566OtherAETNA US HEALTHCARE
Y78152OtherMEDICARE B
8466748OtherCIGNA HEALTH PLAN
042472266OtherPRIVATE HEALTHCARE SYSTEM
NV100511040Medicaid
5617306OtherFIRST HEALTH
042472266OtherTRICARE CHAMPUS
MA0703176Medicaid
5617306OtherFIRST HEALTH
042472266OtherPRIVATE HEALTHCARE SYSTEM
NV100511040Medicaid
NVV102942Medicare PIN