Healthcare Provider Details

I. General information

NPI: 1457342008
Provider Name (Legal Business Name): ALAN B WITKOWER EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MAIN ST STE 101
MEDFORD MA
02155-4540
US

IV. Provider business mailing address

PO BOX 9142
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-7518
  • Fax: 781-391-1030
Mailing address:
  • Phone: 617-724-0287
  • Fax: 617-726-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3000
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: