Healthcare Provider Details

I. General information

NPI: 1154651727
Provider Name (Legal Business Name): MATTHEW EDWARD WITEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W JOHNSON ST APT 714
MADISON WI
53703-3553
US

IV. Provider business mailing address

309 W JOHNSON ST APT 714
MADISON WI
53703-3553
US

V. Phone/Fax

Practice location:
  • Phone: 215-806-4460
  • Fax:
Mailing address:
  • Phone: 215-806-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number62371
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: