Healthcare Provider Details

I. General information

NPI: 1265412308
Provider Name (Legal Business Name): FRED S WITTENSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

2600 WESTHALL LN FL 4
MAITLAND FL
32751-7102
US

V. Phone/Fax

Practice location:
  • Phone: 407-200-2355
  • Fax:
Mailing address:
  • Phone: 407-200-2355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number55078
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number61005
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: