Basic Information
| Provider Information | |||||||||
| NPI: | 1316157779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITEK | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 W PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623343451 | ||||||||
| FaxNumber: | 2623062964 | ||||||||
| Practice Location | |||||||||
| Address1: | W225N16711 CEDAR PARK CT | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530379222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626771101 | ||||||||
| FaxNumber: | 2623062964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 04/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 52622 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.