Healthcare Provider Details

I. General information

NPI: 1447200282
Provider Name (Legal Business Name): BRYAN DAN WITT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 W 10TH ST
HOISINGTON KS
67544-1715
US

IV. Provider business mailing address

353 W 10TH ST
HOISINGTON KS
67544-1715
US

V. Phone/Fax

Practice location:
  • Phone: 620-653-7306
  • Fax: 620-653-2968
Mailing address:
  • Phone: 620-653-7306
  • Fax: 620-653-2968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number21018
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: