Provider Demographics
NPI:1932114725
Name:DEWITT FAMILY PRACTICE
Entity Type:Organization
Organization Name:DEWITT FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:CHARLENE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:870-946-1120
Mailing Address - Street 1:609 W 13TH ST
Mailing Address - Street 2:PO BOX 607
Mailing Address - City:DEWITT
Mailing Address - State:AR
Mailing Address - Zip Code:72042-3001
Mailing Address - Country:US
Mailing Address - Phone:870-946-1120
Mailing Address - Fax:870-946-1132
Practice Address - Street 1:609 W 13TH ST
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:AR
Practice Address - Zip Code:72042-3001
Practice Address - Country:US
Practice Address - Phone:870-946-1120
Practice Address - Fax:870-946-1132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01288ANP261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U757Medicare ID - Type Unspecified
ARF31383Medicare UPIN
AR5J087Medicare ID - Type Unspecified
ARP05830Medicare UPIN