Provider Demographics
NPI:1215943105
Name:WITTOCK, RICHARD FELIX III (DPM)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:FELIX
Last Name:WITTOCK
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1011 BOWLES AVENUE
Mailing Address - Street 2:SUITE 123
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026
Mailing Address - Country:US
Mailing Address - Phone:636-717-1100
Mailing Address - Fax:636-717-1113
Practice Address - Street 1:1011 BOWLES AVENUE
Practice Address - Street 2:SUITE 123
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-717-1100
Practice Address - Fax:636-717-1113
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002003866213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU76476Medicare UPIN
MO6243950001Medicare NSC