Healthcare Provider Details

I. General information

NPI: 1154314888
Provider Name (Legal Business Name): PAUL J WITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 E CAREY ST
PLAINS PA
18705-2007
US

IV. Provider business mailing address

59 E CAREY ST
PLAINS PA
18705-2007
US

V. Phone/Fax

Practice location:
  • Phone: 570-823-7643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD039663L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: