Basic Information
| Provider Information | |||||||||
| NPI: | 1043460850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITTKOPF | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 N MILWAUKEE AVE UNIT 200 | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0901X | 036123362 | IL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 207Y00000X | 036-123362 | IL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1275521288 | 05 | WI | MEDICAID |