Provider Demographics
NPI:1619413127
Name:JT DEWITT D.O.P.A
Entity Type:Organization
Organization Name:JT DEWITT D.O.P.A
Other - Org Name:SYNERGY ELITE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:870-926-5295
Mailing Address - Street 1:2210 W KINGSHIGHWAY
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-3917
Mailing Address - Country:US
Mailing Address - Phone:870-236-2911
Mailing Address - Fax:
Practice Address - Street 1:2210 W KINGSHIGHWAY
Practice Address - Street 2:SUITE 7
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-3917
Practice Address - Country:US
Practice Address - Phone:870-236-2911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty