Provider Demographics
NPI:1013959741
Name:WIITA, BRUCE EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:WIITA
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1002 S OLD DIXIE HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7202
Practice Address - Country:US
Practice Address - Phone:561-747-5885
Practice Address - Fax:561-743-5456
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0014196208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP996325OtherFREEDOM
FLQMP000004225143OtherMOLINA
FLP971351OtherOPTIMUM
FL210784OtherAVMED
FL2180836OtherCIGNA
FL1022104OtherCAREPLUS
FL1261707OtherWELLCARE-MEDICARE
FLP01649432OtherRR MEDICARE
FLP01649432OtherRR MEDICARE
FLP996325OtherFREEDOM
FLQMP000004225143OtherMOLINA