Provider Demographics
NPI:1811146897
Name:WITECK, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:WITECK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:8600 SHERIDAN RD STE 600
Mailing Address - Street 2:KENOSHA DIV OF HEALTH LAB
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6515
Mailing Address - Country:US
Mailing Address - Phone:262-605-6700
Mailing Address - Fax:262-605-6715
Practice Address - Street 1:8600 SHERIDAN RD STE 600
Practice Address - Street 2:KENOSHA DIV OF HEALTH LAB
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6515
Practice Address - Country:US
Practice Address - Phone:262-605-6700
Practice Address - Fax:262-605-6715
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI28122-20246QL0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32924500Medicaid