Provider Demographics
NPI:1720181167
Name:WITTENBORN, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:WITTENBORN
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 120590
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-0590
Mailing Address - Country:US
Mailing Address - Phone:757-867-6102
Mailing Address - Fax:757-867-6588
Practice Address - Street 1:127 WAMSUTTA MILL RD STE D
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5523
Practice Address - Country:US
Practice Address - Phone:828-430-3511
Practice Address - Fax:828-368-4303
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000669207RC0000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCH506E474OtherMEDICARE OF SOUTH CAROLINA
SC835680Medicaid
NCP00060418OtherRR MEDICARE
NC891345JMedicaid
NC1345JOtherBCBS
NC891345JMedicaid