Provider Demographics
NPI:1013980713
Name:WITKOWSKI, EDMUND G (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:G
Last Name:WITKOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-2613
Mailing Address - Country:US
Mailing Address - Phone:941-485-1505
Mailing Address - Fax:941-485-7495
Practice Address - Street 1:3030 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-2613
Practice Address - Country:US
Practice Address - Phone:941-485-1505
Practice Address - Fax:941-485-7495
Is Sole Proprietor?:No
Enumeration Date:2006-02-12
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062096207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG89103Medicare UPIN
FL35350ZMedicare ID - Type Unspecified