Provider Demographics
NPI:1902877079
Name:DETATA, GERALD (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:DETATA
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 1:8 BRIDLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:TABERNACLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08088-9600
Mailing Address - Country:US
Mailing Address - Phone:609-792-1092
Mailing Address - Fax:609-388-4373
Practice Address - Street 1:120 S WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-1804
Practice Address - Country:US
Practice Address - Phone:609-567-2573
Practice Address - Fax:609-561-8046
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04005400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ503586QLLMedicare PIN
NJC55019Medicare UPIN
NJ503586SBVMedicare PIN