Provider Demographics
NPI:1699714964
Name:WITTE, MARK JAY (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAY
Last Name:WITTE
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 1:1249 GLENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-7887
Mailing Address - Country:US
Mailing Address - Phone:402-721-8211
Mailing Address - Fax:
Practice Address - Street 1:3044 S 84TH ST STE 1
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3208
Practice Address - Country:US
Practice Address - Phone:402-391-1143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1097152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist