Provider Demographics
NPI:1851617732
Name:WITTEN, JONATHAN LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LEWIS
Last Name:WITTEN
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 1:6034 SW 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:502-758-0670
Mailing Address - Fax:
Practice Address - Street 1:3920 S DUPONT SQ STE C
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4615
Practice Address - Country:US
Practice Address - Phone:812-282-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01082597A208800000X
ORMD181923208800000X
KY53076208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300028277Medicaid
KY7100626510Medicaid
IN122620025OtherIN MEDICARE