Provider Demographics
NPI:1306870464
Name:WITTMER, MICHAEL JAMES (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:WITTMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6307 HAZELWEST CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1739
Mailing Address - Country:US
Mailing Address - Phone:314-895-3222
Mailing Address - Fax:314-895-8725
Practice Address - Street 1:6307 HAZELWEST CT
Practice Address - Street 2:SUITE 200
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1739
Practice Address - Country:US
Practice Address - Phone:314-895-3222
Practice Address - Fax:314-895-8725
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14206OtherBLUE CROSS/BLUE SHIELD
MO14206OtherBLUE CROSS/BLUE SHIELD