Provider Demographics
NPI:1861464505
Name:WITRYOL, WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:WITRYOL
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 720
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06045-0720
Mailing Address - Country:US
Mailing Address - Phone:860-646-1222
Mailing Address - Fax:860-533-2975
Practice Address - Street 1:29 HAYNES ST STE D
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4139
Practice Address - Country:US
Practice Address - Phone:860-646-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8232204D00000X
MDD68048208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164844601Medicaid
TXF70787Medicare UPIN