Basic Information
| Provider Information | |||||||||
| NPI: | 1609981463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTENBERG | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | SAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
| Address2: | DEPT OF PEDIATRICS SELWYN AVE BLDG SUITE 6D | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189601415 | ||||||||
| FaxNumber: | 7185185124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
| Address2: | ACN-3 PEDS, 4TH FLOOR INPATIENT, 5TH FLOOR NURSERY | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185901800 | ||||||||
| FaxNumber: | 7185185692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 06/20/2011 | ||||||||
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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 | 208000000X | 203517 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | BW4975592 | 01 | DEA NUMBER | OTHER | 203517 | 01 | NY | LICENSE NUMBER | OTHER | 01946978 | 05 | NY | MEDICAID |