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: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-428-5768
  • Fax: 860-374-4646
Mailing address:
  • Phone: 860-428-5768
  • Fax: 860-374-4646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number023759
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: