Provider Demographics
NPI:1760008726
Name:WITTENDORF, MARY ELLEN (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:WITTENDORF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1540 TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-5006
Mailing Address - Country:US
Mailing Address - Phone:574-272-9000
Mailing Address - Fax:574-272-9153
Practice Address - Street 1:1540 TRINITY PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5006
Practice Address - Country:US
Practice Address - Phone:574-272-9000
Practice Address - Fax:574-272-9010
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist