Provider Demographics
NPI:1922441757
Name:WITT, KEVIN LEE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:WITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 S DIXON RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6411
Mailing Address - Country:US
Mailing Address - Phone:765-455-5400
Mailing Address - Fax:
Practice Address - Street 1:221 N CELIA AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303
Practice Address - Country:US
Practice Address - Phone:765-747-3141
Practice Address - Fax:765-747-3175
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01074572A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201185280Medicaid
INP01801391OtherRR MEDICARE
IN194590027Medicare PIN