Provider Demographics
NPI:1740389980
Name:PEWITT, CHARLES S (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:PEWITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2387 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-3018
Mailing Address - Country:US
Mailing Address - Phone:573-243-9288
Mailing Address - Fax:573-204-7074
Practice Address - Street 1:2387 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-3018
Practice Address - Country:US
Practice Address - Phone:573-243-9288
Practice Address - Fax:573-204-7074
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR9F48207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A10692Medicare UPIN