Provider Demographics
NPI:1619937109
Name:DEWITT, HENRY L (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:L
Last Name:DEWITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 OGLETHORPE AVE
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2190
Mailing Address - Country:US
Mailing Address - Phone:706-208-1406
Mailing Address - Fax:706-208-1407
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:SUITE 3300
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2190
Practice Address - Country:US
Practice Address - Phone:706-208-1406
Practice Address - Fax:706-208-1407
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2014-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA027533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000302915CMedicaid
GA52024243005OtherBLUE CROSS BLUE SHIELD
GAP00053435OtherMEDICARE RAILROAD
D29288Medicare UPIN
GA08BBQGDMedicare ID - Type Unspecified