Healthcare Provider Details

I. General information

NPI: 1891157871
Provider Name (Legal Business Name): JACOB SAMUEL WITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 REGENCY PARK STE 100
O FALLON IL
62269-1887
US

IV. Provider business mailing address

PO BOX 25228
DECATUR IL
62525-5228
US

V. Phone/Fax

Practice location:
  • Phone: 618-416-7970
  • Fax: 618-416-7971
Mailing address:
  • Phone: 217-329-3232
  • Fax: 217-233-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036150707
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: