Provider Demographics
NPI:1922024850
Name:WITTUM, ROGER LEE (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LEE
Last Name:WITTUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4240 SUN 'N LAKE BOULEVARD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872
Mailing Address - Country:US
Mailing Address - Phone:863-471-3926
Mailing Address - Fax:863-385-3093
Practice Address - Street 1:4240 SUN 'N LAKE BOULEVARD
Practice Address - Street 2:SUITE 202
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872
Practice Address - Country:US
Practice Address - Phone:863-471-3926
Practice Address - Fax:863-385-3093
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102099207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000446200Medicaid
FL000446200Medicaid