Provider Demographics
NPI:1417342890
Name:DEWITT, COREY (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
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 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-433-8643
Practice Address - Street 1:19465 DEERFIELD AVENUE, SUITE 401
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-1707
Practice Address - Country:US
Practice Address - Phone:703-723-5700
Practice Address - Fax:703-723-5778
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD23389207N00000X
MDD91604207ND0101X
VA0101275415207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017465030001Medicaid
VA1417342890Medicaid