Provider Demographics
NPI:1871632315
Name:WILLIAM M. WIXTED M.D., P.C.
Entity Type:Organization
Organization Name:WILLIAM M. WIXTED M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIXTED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-653-0199
Mailing Address - Street 1:731 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2342
Mailing Address - Country:US
Mailing Address - Phone:609-653-0199
Mailing Address - Fax:609-653-9411
Practice Address - Street 1:731 BAY AVE
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2342
Practice Address - Country:US
Practice Address - Phone:609-653-0199
Practice Address - Fax:609-653-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02912900208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1336188572OtherPERSONEL NPI#
NJ25MA02912900OtherLICENSE
NJ=========OtherTAX ID FOR CORP
NJ25MA02912900OtherLICENSE