Healthcare Provider Details

I. General information

NPI: 1104824580
Provider Name (Legal Business Name): PETER B WITTSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2254 OLYMPIC ST
SPRINGFIELD OH
45503-2737
US

IV. Provider business mailing address

2254 OLYMPIC ST
SPRINGFIELD OH
45503-2737
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-8287
  • Fax:
Mailing address:
  • Phone: 937-399-8287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35068089W
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: