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General NPI Number Information
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NPI Number | 1497721088
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Entity Type | Individual
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Provider Name | MARK D WITTRY MD
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Gender | Male
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Dates
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Enumeration Date | 02/24/2006
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Last Update Date | 02/22/2016
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Provider Practice Location Address
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Address Line | 615 S NEW BALLAS RD DEPT OF NUCLEAR MEDICINE
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8221
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Country | US
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Telephone | 314-251-6465
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Fax | 314-251-4286
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Provider Business Mailing Address
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Address Line | 11475 OLDE CABIN RD SUITE 200
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City | SAINT LOUIS
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State | MO
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Zip | 63141-7128
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Country | US
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Telephone | 314-991-8200
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Fax | 314-991-8206
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | R5F02
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207U00000X
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Taxonomy Name | Nuclear Medicine Physician
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License Number | R5F02
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | R5F02
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 207UN0902X
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Taxonomy Name | Nuclear Imaging & Therapy Physician
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License Number | R5F02
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License Number State | MO
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Taxonomy #5
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Taxonomy Code | 207U00000X
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Taxonomy Name | Nuclear Medicine Physician
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License Number | 036069181
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License Number State | IL
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