Healthcare Provider Details

I. General information

NPI: 1588657654
Provider Name (Legal Business Name): FREDERICK R WITTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL BLVD
JEFFERSONVILLE IN
47130-3769
US

IV. Provider business mailing address

101 HOSPITAL BLVD
JEFFERSONVILLE IN
47130-3769
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-3899
  • Fax: 812-282-4172
Mailing address:
  • Phone: 812-282-3899
  • Fax: 812-282-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01040421A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number23489
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: