Provider Demographics
NPI:1366474207
Name:DEWITT, PAUL R (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:DEWITT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 61 BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514-9600
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:
Practice Address - Street 1:US HWY 160 & NAVAJO ROUTE 35 - RED MESA
Practice Address - Street 2:
Practice Address - City:TEECNOSPOS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ796063Medicaid
NM65837533Medicaid
NM65837533Medicaid
AZ796063Medicaid
TX8HC131Medicare ID - Type UnspecifiedHSZ001