Basic Information
| Provider Information | |||||||||
| NPI: | 1306289665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITTRY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 S 17TH ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685023763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024838590 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2221 S 17TH ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024838590 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2013 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 1846 | NE | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 1846 | NE | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.