Provider Demographics
NPI:1548458623
Name:WILLIAM B. WITTE, LTD
Entity type:Organization
Organization Name:WILLIAM B. WITTE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:RIEGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:309-663-8581
Mailing Address - Street 1:2409 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4483
Mailing Address - Country:US
Mailing Address - Phone:309-663-8581
Mailing Address - Fax:309-663-0232
Practice Address - Street 1:2409 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4483
Practice Address - Country:US
Practice Address - Phone:309-663-8581
Practice Address - Fax:309-663-0232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-14
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5784001OtherBLUE CROSS BLUE SHIELD
IL0282420001OtherDMERC SUPPLIER