Provider Demographics
NPI:1902105513
Name:WITTENBERG, BETH (MD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:WITTENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL
Mailing Address - Street 2:BOX 1508
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6504
Mailing Address - Country:US
Mailing Address - Phone:212-241-6186
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:BOX 1508
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:212-241-6186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC37272208000000X
NY269930-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC372723Medicaid
SCSC38557043Medicare PIN