Provider Demographics
NPI:1902994197
Name:WITTNER, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WITTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2865 ATLANTIC AVE
Mailing Address - Street 2:STE 149
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-7411
Mailing Address - Country:US
Mailing Address - Phone:562-595-1879
Mailing Address - Fax:562-595-0135
Practice Address - Street 1:2865 ATLANTIC AVE
Practice Address - Street 2:STE 149
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-7411
Practice Address - Country:US
Practice Address - Phone:562-595-1879
Practice Address - Fax:562-595-0135
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG163782080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG163780Medicaid
A90424Medicare UPIN