Provider Demographics
NPI:1659770030
Name:DEWITT MEDICAL DISTRICT
Entity Type:Organization
Organization Name:DEWITT MEDICAL DISTRICT
Other - Org Name:PARKSIDE FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:FALCONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-275-6191
Mailing Address - Street 1:1109 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-2108
Mailing Address - Country:US
Mailing Address - Phone:361-275-2800
Mailing Address - Fax:361-275-8791
Practice Address - Street 1:1109 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-2108
Practice Address - Country:US
Practice Address - Phone:361-275-2800
Practice Address - Fax:361-275-8791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344242801Medicaid
TX350897001Medicaid
TX350897002Medicaid
TX350897002Medicaid
TX673423Medicare PIN