Provider Demographics
NPI:1720353089
Name:WITT, DARRELL (MD)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:WITT
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 1:1928 DUBAY DR
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-9366
Mailing Address - Country:US
Mailing Address - Phone:715-457-6521
Mailing Address - Fax:
Practice Address - Street 1:1928 DUBAY DR
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-9366
Practice Address - Country:US
Practice Address - Phone:715-457-6521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16087-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine