Provider Demographics
NPI:1649457524
Name:BRUCE R WITTEN MD PA
Entity type:Organization
Organization Name:BRUCE R WITTEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-829-6441
Mailing Address - Street 1:301 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 323
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5793
Mailing Address - Country:US
Mailing Address - Phone:904-829-6441
Mailing Address - Fax:904-829-2452
Practice Address - Street 1:301 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 323
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5793
Practice Address - Country:US
Practice Address - Phone:904-829-6441
Practice Address - Fax:904-829-2452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0013869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD65694Medicare UPIN
FL33591Medicare PIN