Healthcare Provider Details

I. General information

NPI: 1902877079
Provider Name (Legal Business Name): GERALD DETATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S WHITE HORSE PIKE
HAMMONTON NJ
08037-1804
US

IV. Provider business mailing address

8 BRIDLEWOOD CT
TABERNACLE NJ
08088-9600
US

V. Phone/Fax

Practice location:
  • Phone: 609-567-2573
  • Fax: 609-561-8046
Mailing address:
  • Phone: 609-792-1092
  • Fax: 609-388-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA04005400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: