Healthcare Provider Details

I. General information

NPI: 1376518431
Provider Name (Legal Business Name): CHARLES N WITTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 W LAKE MARY BLVD STE 215
LAKE MARY FL
32746-3344
US

IV. Provider business mailing address

4106 W LAKE MARY BLVD STE 215
LAKE MARY FL
32746-3344
US

V. Phone/Fax

Practice location:
  • Phone: 407-332-7700
  • Fax: 321-275-0339
Mailing address:
  • Phone: 407-332-7700
  • Fax: 321-275-0339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME0057403
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: