Provider Demographics
NPI:1134189129
Name:WITTER, LORI A (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:WITTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:WITTER-SARGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:8100 W 78TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2516
Practice Address - Country:US
Practice Address - Phone:952-914-8100
Practice Address - Fax:952-914-8100
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33850207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E51721Medicare UPIN