Basic Information
| Provider Information | |||||||||
| NPI: | 1285602920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTENBERG | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416212200 | ||||||||
| FaxNumber: | 6416212335 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | PELLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502191189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416212200 | ||||||||
| FaxNumber: | 6416212335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30144 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080098974 | 01 | IA | RAILROAD MEDICARE | OTHER | 2120105 | 05 | IA | MEDICAID |