Provider Demographics
NPI:1174587604
Name:GITTELMAN, MARC C (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:C
Last Name:GITTELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:21150 BISCAYNE BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1226
Practice Address - Country:US
Practice Address - Phone:305-466-9111
Practice Address - Fax:305-466-9127
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME53015174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001601400Medicaid
FL05776OtherBCBS FL
FLP0003164OtherFLORIDA HEALTHCARE PLUS
FL4068398OtherAETNA PROVIDER #
FLP00721039OtherRR MEDICARE
FLQMP000004462340OtherMOLINA
FL1193060OtherWELLCARE
FLP01730303OtherSIMPLY HEALTHCARE
FLD51418Medicare UPIN
FL21199FMedicare PIN
FL05776YMedicare PIN
FL05776XMedicare PIN
FLQMP000004462340OtherMOLINA