1639596091 NPI number — JT DEWITT D.O.P.A.

Table of content: (NPI 1639596091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639596091 NPI number — JT DEWITT D.O.P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JT DEWITT D.O.P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639596091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3071 HIGHWAY 34 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARMADUKE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72443-9773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-897-8433
Provider Business Mailing Address Fax Number:
870-897-8438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11998 HIGHWAY 49 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARMADUKE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72443-9597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-897-8433
Provider Business Practice Location Address Fax Number:
870-897-8438
Provider Enumeration Date:
03/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DEWITT
Authorized Official First Name:
JT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
870-897-8433

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  E4975 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 175408003 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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