Provider Demographics
NPI:1972658276
Name:WITTIG, SUZANNE HERTEN (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:HERTEN
Last Name:WITTIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 TYSONS BLVD STE 1160
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4230
Mailing Address - Country:US
Mailing Address - Phone:571-341-9450
Mailing Address - Fax:571-341-9453
Practice Address - Street 1:1750 TYSONS BLVD STE 1160
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4230
Practice Address - Country:US
Practice Address - Phone:571-341-9450
Practice Address - Fax:571-341-9453
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101224614207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1972658276Medicaid
H58443Medicare UPIN