Provider Demographics
NPI:1861646390
Name:MARY BETH WITTMAN M.D. PLLC
Entity Type:Organization
Organization Name:MARY BETH WITTMAN M.D. PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:WITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-899-5000
Mailing Address - Street 1:12303 NE 130TH LN STE 450
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3032
Mailing Address - Country:US
Mailing Address - Phone:425-899-5000
Mailing Address - Fax:425-899-5006
Practice Address - Street 1:12303 NE 130TH LN STE 450
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3032
Practice Address - Country:US
Practice Address - Phone:425-899-5000
Practice Address - Fax:425-899-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036040207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7104417Medicaid
WA7104417Medicaid
WAG71046Medicare UPIN