Provider Demographics
NPI:1386160521
Name:WITTMAN, JACOB (OD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:WITTMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 GRACE CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4717
Mailing Address - Country:US
Mailing Address - Phone:920-470-0632
Mailing Address - Fax:
Practice Address - Street 1:1225 W NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1416
Practice Address - Country:US
Practice Address - Phone:920-731-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3490-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty