Basic Information
| Provider Information | |||||||||
| NPI: | 1184699472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITUCKI | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838507 | ||||||||
| FaxNumber: | 2699854535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 03087 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 57339 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083P0011X | 57339 | WI | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100075950 | 05 | KY | MEDICAID | 3300156 | 05 | TN | MEDICAID | 000000601505 | 01 | KY | ANTHEM | OTHER |