Provider Demographics
NPI:1770550782
Name:WITKOP, PHILIP D (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
Last Name:WITKOP
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 1:2431 WILEY BLVD SW # 1013
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-6003
Mailing Address - Country:US
Mailing Address - Phone:319-666-4224
Mailing Address - Fax:877-384-3106
Practice Address - Street 1:1300 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-2887
Practice Address - Country:US
Practice Address - Phone:319-666-4224
Practice Address - Fax:877-384-3106
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098344207P00000X
IA49469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098344Medicaid
ILK34834Medicare PIN
IL207236016Medicare PIN
ILG86033Medicare UPIN