Basic Information
| Provider Information | |||||||||
| NPI: | 1093956039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | SHARON LEE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONDO | ||||||||
| OtherFirstName: | SHARON LEE | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 62707 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339062707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399313440 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24600 S TAMIAMI TRL | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341347022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399483761 | ||||||||
| FaxNumber: | 2399483762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2009 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101020198 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS 12648 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14Y3Q | 01 | FL | FLORIDA BLUE | OTHER | 015961500 | 05 | FL | MEDICAID |