Provider Demographics
NPI:1538144548
Name:WILTERDINK, DAVID MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARTIN
Last Name:WILTERDINK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 GREEN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:DANIELSON
Mailing Address - State:CT
Mailing Address - Zip Code:06239-3509
Mailing Address - Country:US
Mailing Address - Phone:860-774-1255
Mailing Address - Fax:860-779-2059
Practice Address - Street 1:45 GREEN HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-3509
Practice Address - Country:US
Practice Address - Phone:860-774-1255
Practice Address - Fax:860-779-2059
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023759207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001237593Medicaid
CT001237593Medicaid
CTB84342Medicare UPIN