Provider Demographics
NPI:1396907069
Name:GITMAN, MARAT (DO)
Entity type:Individual
Prefix:
First Name:MARAT
Middle Name:
Last Name:GITMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2845
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:
Practice Address - Street 1:5 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3372
Practice Address - Country:US
Practice Address - Phone:860-253-9024
Practice Address - Fax:860-253-9593
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49820207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid