Basic Information
| Provider Information | |||||||||
| NPI: | 1972658276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITTIG | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | HERTEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1750 TYSONS BLVD STE 1160 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221024230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713419450 | ||||||||
| FaxNumber: | 5713419453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1750 TYSONS BLVD STE 1160 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221024230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713419450 | ||||||||
| FaxNumber: | 5713419453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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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 | 207R00000X | 0101224614 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1972658276 | 05 | VA | MEDICAID |