Provider Demographics
NPI:1871561654
Name:WITTENBERG, MARC I (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:I
Last Name:WITTENBERG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:799 DENISON CT
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0301
Mailing Address - Country:US
Mailing Address - Phone:248-751-7246
Mailing Address - Fax:248-418-2311
Practice Address - Street 1:799 DENISON CT FL 2
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0053
Practice Address - Country:US
Practice Address - Phone:248-751-7246
Practice Address - Fax:248-418-2311
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMW058094208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871561654Medicaid
F93593Medicare UPIN
MI0N37000Medicare PIN