Active NPI
Mary Ellen Wittendorf, OD
- Optometrist
- Mishawaka, IN
National Provider Identifier
1760008726
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 4901005437
- Practice address
- 1540 Trinity PL
Mishawaka, IN 46545-5006 - Phone
- (574) 272-9000
- Fax
- (574) 272-9010
- NPI assigned
- Jun 24, 2020
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 4901005437 | MI | Primary |
Addresses
Primary practice location
1540 Trinity PL
Mishawaka, IN 46545-5006
Mailing address
1540 Trinity PL
Mishawaka, IN 46545-5006
Phone (574) 272-9000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4901005437 | MI | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1592956800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1688342400000",
"number": "1760008726",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1540 TRINITY PL",
"city": "MISHAWAKA",
"state": "IN",
"postal_code": "465455006",
"telephone_number": "574-272-9000",
"fax_number": "574-272-9153"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1540 TRINITY PL",
"city": "MISHAWAKA",
"state": "IN",
"postal_code": "465455006",
"telephone_number": "574-272-9000",
"fax_number": "574-272-9010"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WITTENDORF",
"first_name": "MARY",
"middle_name": "ELLEN",
"credential": "OD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2020-06-24",
"last_updated": "2023-07-03",
"certification_date": "2023-07-03",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "MI",
"license": "4901005437",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Mishawaka, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 3, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.