Provider Demographics
NPI:1306829890
Name:WITTE, MARIE LORETTA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:LORETTA
Last Name:WITTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIE
Other - Middle Name:LORETTA
Other - Last Name:MALCOLM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4304
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:SUITE 401
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6654
Practice Address - Fax:864-560-6017
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46432207R00000X
SC34635207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC346352Medicaid
NC5922248Medicaid
MN766159200Medicaid
WI34518500Medicaid
P00202258Medicare UPIN
MN766159200Medicaid
MNI05759Medicare UPIN
NC5922248Medicaid
WI34518500Medicaid