Provider Demographics
NPI:1457423303
Name:WITTMANN, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WITTMANN
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 1:717 W MORELAND BLVD
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCITES MORELAND FAMILY MEDICI
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2432
Mailing Address - Country:US
Mailing Address - Phone:262-542-9100
Mailing Address - Fax:262-542-7366
Practice Address - Street 1:717 W MORELAND BLVD
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCITES MORELAND FAMILY MEDICI
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2432
Practice Address - Country:US
Practice Address - Phone:262-542-9100
Practice Address - Fax:262-542-7366
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000568575Medicare ID - Type Unspecified
B57696Medicare UPIN
68375Medicare PIN