Provider Demographics
NPI:1336188572
Name:WIXTED, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:WIXTED
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 1:731 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2342
Mailing Address - Country:US
Mailing Address - Phone:609-653-1863
Mailing Address - Fax:609-601-1406
Practice Address - Street 1:731 BAY AVE
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2342
Practice Address - Country:US
Practice Address - Phone:609-653-1863
Practice Address - Fax:609-601-1406
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02912900208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ222205797OtherTAX ID
NJ25MA02912900OtherSTATE LICENSE
NJC58649Medicare UPIN
NJ423307Medicare ID - Type UnspecifiedGROUP ID