Provider Demographics
NPI:1114960473
Name:FORTENBERRY, DEWITT CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:DEWITT
Middle Name:CHARLES
Last Name:FORTENBERRY
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 1:116 WESTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-0006
Mailing Address - Country:US
Mailing Address - Phone:903-293-7093
Mailing Address - Fax:
Practice Address - Street 1:2602 SAINT MICHAEL DR
Practice Address - Street 2:SUITE 302
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2387
Practice Address - Country:US
Practice Address - Phone:903-336-2391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8691207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167594401Medicaid
TX8F6412Medicare PIN
TX167594401Medicaid
TX8C1136Medicare ID - Type Unspecified