Provider Demographics
NPI:1740226729
Name:WITTSTEIN, ILAN (MD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:
Last Name:WITTSTEIN
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 64250
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4250
Mailing Address - Country:US
Mailing Address - Phone:410-502-0550
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD44768207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD643331600Medicaid
MD643331600Medicaid
MDKR34066WMedicare PIN