1275863243 NPI number — JOHN T. WITTE, M.D., P.A.

Table of content: (NPI 1275863243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275863243 NPI number — JOHN T. WITTE, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN T. WITTE, M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275863243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 W BANNOCK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83702-6035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-343-1702
Provider Business Mailing Address Fax Number:
208-342-7042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2235 E GALA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-3724
Provider Business Practice Location Address Fax Number:
208-887-1682
Provider Enumeration Date:
01/13/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WITTE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
208-343-6458

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  M5529 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002733600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".