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

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 Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME0013869
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: