Provider Demographics
NPI:1700882644
Name:WITTEN, RICHARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:WITTEN
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 1:540 S MARENGO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3130
Mailing Address - Country:US
Mailing Address - Phone:626-397-4910
Mailing Address - Fax:626-397-4911
Practice Address - Street 1:6363 WILSHIRE BLVD
Practice Address - Street 2:STE 320A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5730
Practice Address - Country:US
Practice Address - Phone:323-653-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG7782174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G77820OtherBLUE SHIELD OF CA
CAA58014Medicare UPIN
CAG7782Medicare ID - Type UnspecifiedDR. WITTEN