Provider Demographics
NPI:1811657687
Name:JONATHANDWITZKEMD, PLLC
Entity type:Organization
Organization Name:JONATHANDWITZKEMD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WITZKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-925-1111
Mailing Address - Street 1:8170 33RD AVE
Mailing Address - Street 2:MS: 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-8290
Mailing Address - Fax:651-254-8299
Practice Address - Street 1:7450 FRANCE AVE S STE 220
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4792
Practice Address - Country:US
Practice Address - Phone:952-925-1111
Practice Address - Fax:952-922-3446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty