MEDICARE: DR. GERALD DETATA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25MA04005400	NJ

General Provider Information

NPI Number	:	1902877079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GERALD DETATA MD

Provider Business Mailing Address
First Line	:	8 BRIDLEWOOD CT
Second Line	:
City	:	TABERNACLE
State	:	NJ
Zip	:	08088-9600
Country	:	US
Telephone Number	:	609-792-1092
Fax Number	:	609-388-4373

Provider Business Practice Location Address
First Line	:	120 S WHITE HORSE PIKE
Second Line	:
City	:	HAMMONTON
State	:	NJ
Zip	:	08037-1804
Country	:	US
Telephone Number	:	609-567-2573
Fax Number	:	609-561-8046

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	04/27/2016

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