Basic Information
| Provider Information | |||||||||
| NPI: | 1750733614 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WITWIT | ||||||||
| FirstName: | WISAM | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321645980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865862000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321645980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865862000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2016 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301110641 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085N0700X | ME155790 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
No ID Information.