Provider Demographics
NPI:1336761337
Name:WITTENAUER, CAMDEN LAWRENCE
Entity Type:Individual
Prefix:
First Name:CAMDEN
Middle Name:LAWRENCE
Last Name:WITTENAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23738 CASTLE ROCK
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1899
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1127 WILSHIRE BLVD STE 1504
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4006
Practice Address - Country:US
Practice Address - Phone:323-329-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program