Healthcare Provider Details

I. General information

NPI: 1366627499
Provider Name (Legal Business Name): GREGORY P. WITTPENN, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3616 N UNIVERSITY DR
NACOGDOCHES TX
75965-2539
US

IV. Provider business mailing address

3616 N UNIVERSITY DR
NACOGDOCHES TX
75965-2539
US

V. Phone/Fax

Practice location:
  • Phone: 936-564-3744
  • Fax:
Mailing address:
  • Phone: 936-564-3744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY PAUL WITTPENN
Title or Position: PHYSICIAN
Credential:
Phone: 936-564-3744