Basic Information
| Provider Information | |||||||||
| NPI: | 1306340625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITTKE | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 W NORTH AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606101042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122800996 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 711 W NORTH AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606101042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122800996 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2018 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036155604 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.