1255319877 NPI number — DR. PETER C WITT MD

Table of content: DR. PETER C WITT MD (NPI 1255319877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255319877 NPI number — DR. PETER C WITT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITT
Provider First Name:
PETER
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1255319877
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87499-6210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-609-2258
Provider Business Mailing Address Fax Number:
505-609-2259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 W MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-6113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-609-6349
Provider Business Practice Location Address Fax Number:
505-599-4679
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  49164 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: 34642 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: MD2015-0843 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1255319877 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01346428 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1J2390 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10025926100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00944654 . This is a "MEDICARE RAILROAD CARRIER PTAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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