Healthcare Provider Details

I. General information

NPI: 1649457524
Provider Name (Legal Business Name): BRUCE R WITTEN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HEALTH PARK BLVD SUITE 323
ST AUGUSTINE FL
32086-5793
US

IV. Provider business mailing address

301 HEALTH PARK BLVD SUITE 323
ST AUGUSTINE FL
32086-5793
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-6441
  • Fax: 904-829-2452
Mailing address:
  • Phone: 904-829-6441
  • Fax: 904-829-2452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0013869
License Number StateFL

VIII. Authorized Official

Name: DR. BRUCE RICHARD WITTEN
Title or Position: OWNER
Credential: M.D.
Phone: 904-829-6441