Provider Demographics
NPI:1790189728
Name:CARL C. GITTENS MD PA
Entity Type:Organization
Organization Name:CARL C. GITTENS MD PA
Other - Org Name:CARL C. GITTENS MD PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GITTENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-215-5905
Mailing Address - Street 1:789 SW FEDERAL HWY
Mailing Address - Street 2:SUITE 212
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 SW FEDERAL HWY
Practice Address - Street 2:SUITE 212
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2962
Practice Address - Country:US
Practice Address - Phone:772-215-5905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53378251S00000X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME53378OtherLICENSE NUMBER