Provider Demographics
NPI:1164501003
Name:WITZELING, TODD MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:WITZELING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E 15TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4111
Mailing Address - Country:US
Mailing Address - Phone:307-234-9657
Mailing Address - Fax:307-234-0306
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:307-577-2123
Practice Address - Fax:307-577-2239
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4438A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
050036353OtherRAILROAD MEDICARE
050010204OtherRAILROAD MEDICARE
WY103996201Medicaid
306554OtherBLUE SHIELD
307122OtherBLUE SHIELD
WY103996200Medicaid
WY103996200Medicaid
W307122Medicare PIN
050036353OtherRAILROAD MEDICARE