Provider Demographics
NPI:1023165644
Name:WITTMAN, RANDY S (MD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:S
Last Name:WITTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1379
Mailing Address - Country:US
Mailing Address - Phone:630-653-4240
Mailing Address - Fax:630-315-6597
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1379
Practice Address - Country:US
Practice Address - Phone:630-653-4240
Practice Address - Fax:630-315-6597
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072670207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072670 2Medicaid
D16588Medicare UPIN
IL036072670 2Medicaid