Provider Demographics
NPI:1780907576
Name:WITT, RUSSELL G (MD, MAS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:G
Last Name:WITT
Suffix:
Gender:M
Credentials:MD, MAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:
Practice Address - Street 1:1240 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0817
Practice Address - Country:US
Practice Address - Phone:434-243-5233
Practice Address - Fax:434-244-9437
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS5808208600000X, 2086X0206X
VA0101278257208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX417055702OtherMEDICAID- CSHCN
TX417055701Medicaid