Provider Demographics
NPI:1972706794
Name:WITTER, MARCUS MICHAEL (PT)
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:MICHAEL
Last Name:WITTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 N 129TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-4239
Mailing Address - Country:US
Mailing Address - Phone:402-616-3437
Mailing Address - Fax:402-496-3595
Practice Address - Street 1:4300 SOUTH LAKEPORT ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106
Practice Address - Country:US
Practice Address - Phone:712-266-0707
Practice Address - Fax:712-266-0709
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist