Provider Demographics
NPI:1053381657
Name:WITTKOPP, THOMAS ARNO (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ARNO
Last Name:WITTKOPP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 SOUTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:GREENBACK
Mailing Address - State:TN
Mailing Address - Zip Code:37742-2301
Mailing Address - Country:US
Mailing Address - Phone:218-831-1535
Mailing Address - Fax:
Practice Address - Street 1:3301 7TH AVE
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-4516
Practice Address - Country:US
Practice Address - Phone:651-431-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN198172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN118773200Medicaid
MN118773200Medicaid
MN19064Medicare ID - Type Unspecified