Provider Demographics
NPI:1104960822
Name:WITTKOP, MARY E
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WITTKOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CURTIS CT
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1102
Mailing Address - Country:US
Mailing Address - Phone:303-466-2119
Mailing Address - Fax:
Practice Address - Street 1:11245 HURON ST
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-2806
Practice Address - Country:US
Practice Address - Phone:303-457-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48590207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
003835OtherKAISER-COMMERCIAL NUMBER