Provider Demographics
NPI:1750348587
Name:WITTELS, EDWARD GERARD (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:GERARD
Last Name:WITTELS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SUMMIT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2853
Mailing Address - Country:US
Mailing Address - Phone:401-793-4001
Mailing Address - Fax:401-793-4049
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:FAIN 3
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-2920
Practice Address - Fax:401-793-2859
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05201207RH0003X
MA70358207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9001997Medicaid
RI9001997Medicaid