Basic Information
| Provider Information | |||||||||
| NPI: | 1629145115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITTENBORN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 363 | ||||||||
| Address2: | |||||||||
| City: | BERNARDSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079240363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086968940 | ||||||||
| FaxNumber: | 6092617199 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 UNION AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BRIDGEWATER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088073063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092615755 | ||||||||
| FaxNumber: | 6092617199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MA070083 | NJ | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 669902 | 01 | HIGHMARK | OTHER | 0231523000 | 01 | AMERIHEALTH KEYSTONE PC | OTHER | 1161130 | 01 | MECY HORIZON NJ HEALTH | OTHER | 2336458 | 01 | NJ | AETNA | OTHER | P2052026 | 01 | OXFORD | OTHER |