Healthcare Provider Details

I. General information

NPI: 1396741849
Provider Name (Legal Business Name): GARY BRUCE WITKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-0001
US

IV. Provider business mailing address

PO BOX 12210
WILMINGTON DE
19850-2210
US

V. Phone/Fax

Practice location:
  • Phone: 302-454-9830
  • Fax: 302-454-1445
Mailing address:
  • Phone: 302-454-9830
  • Fax: 302-454-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC10003207
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: