Healthcare Provider Details
I. General information
NPI: 1962425207
Provider Name (Legal Business Name): BRUCE R WITTEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y
II. Dates (important events)
Enumeration Date: 07/26/2006
Last Update Date: 07/09/2007
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
- Phone: 904-829-6441
- Fax: 904-829-2452
- Phone: 904-829-6441
- Fax: 904-829-2452
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 207Y00000X |
| Taxonomy | Otolaryngology Physician |
| License Number | ME0013869 |
| License Number State | FL |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone: