Provider Demographics
NPI:1578530507
Name:KWITTKEN, PAMELA LAURIE (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LAURIE
Last Name:KWITTKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 COMMERCE PARK
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3535
Mailing Address - Country:US
Mailing Address - Phone:203-795-9795
Mailing Address - Fax:203-795-0482
Practice Address - Street 1:40 COMMERCE PARK
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3535
Practice Address - Country:US
Practice Address - Phone:203-795-9795
Practice Address - Fax:203-795-0482
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033471207KA0200X, 208000000X
NY177320207KA0200X
NJ25MA07491400207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001334713Medicaid
CT001334713Medicaid
CT030000114Medicare PIN