Provider Demographics
NPI:1922441757
Name:WITT, KEVIN LEE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:WITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10101 ERNST RD STE 1200
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IN
Practice Address - Zip Code:46783-9711
Practice Address - Country:US
Practice Address - Phone:260-234-5400
Practice Address - Fax:260-235-5410
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01074572A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102404078OtherANTHEM PTAN
INP01801391OtherRR MEDICARE
IN201185280Medicaid
IN000001525811OtherANTHEM PTAN
IN1922441757OtherANTHEM PTAN
IN000001030505OtherANTHEM PTAN