Healthcare Provider Details

I. General information

NPI: 1538144548
Provider Name (Legal Business Name): DAVID MARTIN WILTERDINK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GREEN HOLLOW RD
DANIELSON CT
06239-3509
US

IV. Provider business mailing address

45 GREEN HOLLOW RD
DANIELSON CT
06239-3509
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-1255
  • Fax: 860-779-2059
Mailing address:
  • Phone: 860-774-1255
  • Fax: 860-779-2059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number023759
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number023759
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001237593
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: