Provider Demographics
NPI:1336152529
Name:WITT, DARRELL L (OD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:L
Last Name:WITT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 STUART ST
Mailing Address - Street 2:MACH ATTN: MCXL-PQ (CREDENTIALS)
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5720
Mailing Address - Country:US
Mailing Address - Phone:803-751-2618
Mailing Address - Fax:803-751-2689
Practice Address - Street 1:4500 STUART ST
Practice Address - Street 2:MACH/CREDENTIALS
Practice Address - City:FORT JACKSON
Practice Address - State:SC
Practice Address - Zip Code:29207-5720
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN
U83043059Medicare ID - Type Unspecified
U8304Medicare UPIN