Healthcare Provider Details

I. General information

NPI: 1700868643
Provider Name (Legal Business Name): LEE A WITTENBERG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 N TENAYA WAY STE 200
LAS VEGAS NV
89128-1404
US

IV. Provider business mailing address

2901 N TENAYA WAY STE 200
LAS VEGAS NV
89128-1404
US

V. Phone/Fax

Practice location:
  • Phone: 702-362-2622
  • Fax: 702-362-0422
Mailing address:
  • Phone: 702-362-2622
  • Fax: 702-362-0422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2301
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2949
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0607
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: