Provider Demographics
NPI:1093714834
Name:DEWITT, DEXTER D (MD)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:D
Last Name:DEWITT
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 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5488
Practice Address - Country:US
Practice Address - Phone:928-468-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6525208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0851710OtherBCBS
AZ0017101703Medicaid
AZAZ0851710OtherBCBS
AZZ29848Medicare PIN