Provider Demographics
NPI:1891796702
Name:VITTIMBERGA, GWENN MARIA (MD)
Entity type:Individual
Prefix:
First Name:GWENN
Middle Name:MARIA
Last Name:VITTIMBERGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1180 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-1126
Mailing Address - Country:US
Mailing Address - Phone:401-253-8900
Mailing Address - Fax:401-254-1093
Practice Address - Street 1:1180 HOPE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-1126
Practice Address - Country:US
Practice Address - Phone:401-253-8900
Practice Address - Fax:401-254-1093
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD 7158207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI03-00134OtherUNITED HEALTH CARE
RI201972OtherBCHIP
RI401452OtherHARVARD PILGRIM HEALTH
RI007158OtherTUFTS
RI20074-3OtherB/S
RI3804OtherNEIGHBORHOOD HEALTH
RI9020074Medicaid
RI401452OtherHARVARD PILGRIM HEALTH