Provider Demographics
NPI:1962425207
Name:WITTEN, BRUCE R (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:WITTEN
Suffix:
Gender:M
Credentials:MD
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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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
FLME0013869207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD65694Medicare UPIN
FL91958Medicare ID - Type UnspecifiedFLORIDA MEDICARE