Provider Demographics
NPI:1215936729
Name:WITTE, NICOLE M (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WITTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:MEZSICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-845-2500
Mailing Address - Fax:630-845-9928
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:SUITE 306
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-845-2500
Practice Address - Fax:630-845-9928
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111855207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532211OtherBLUE CROSS BLUE SHIELD GROUP NUMBER
IL036111855Medicaid
IL036111855Medicaid
IL214979Medicare PIN
IL04532211OtherBLUE CROSS BLUE SHIELD GROUP NUMBER
ILK12554Medicare PIN
IL201737Medicare PIN