Provider Demographics
NPI:1730130659
Name:ERICKSON WITTMANN, BETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:A
Last Name:ERICKSON WITTMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-4400
Mailing Address - Fax:414-805-4405
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-4400
Practice Address - Fax:414-805-4405
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI269612085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000115MOtherHUMANA
WI1730130659Medicaid
0009268086Medicare ID - Type Unspecified
WI0049 73601Medicare PIN
B52651Medicare UPIN