Provider Demographics
NPI:1609981463
Name:WITTENBERG, IAN SAUL (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:SAUL
Last Name:WITTENBERG
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:DEPT OF PEDIATRICS SELWYN AVE BLDG SUITE 6D
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7606
Mailing Address - Country:US
Mailing Address - Phone:718-960-1415
Mailing Address - Fax:718-518-5124
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:ACN-3 PEDS, 4TH FLOOR INPATIENT, 5TH FLOOR NURSERY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7606
Practice Address - Country:US
Practice Address - Phone:718-590-1800
Practice Address - Fax:718-518-5692
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
NY203517208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY203517OtherLICENSE NUMBER
NY01946978Medicaid
NY01946978Medicaid
NYH68787Medicare UPIN