Healthcare Provider Details

I. General information

NPI: 1124026539
Provider Name (Legal Business Name): JOHN GERARD BITWINSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N 100 E
PRESTON ID
83263-1326
US

IV. Provider business mailing address

PO BOX 1108
BOUNTIFUL UT
84011-1108
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-1937
  • Fax:
Mailing address:
  • Phone: 801-296-2113
  • Fax: 801-296-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-8805
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: