Provider Demographics
NPI:1255340691
Name:WITTENBORN, JEREMY SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SCOTT
Last Name:WITTENBORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:630-491-5472
Practice Address - Street 1:5510 S EAST ST STE H
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1939
Practice Address - Country:US
Practice Address - Phone:317-924-8425
Practice Address - Fax:317-924-8424
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062568A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000612520OtherANTHEM PIN
IN200836520Medicaid
IN076330Medicare PIN