Provider Demographics
NPI:1932511672
Name:DEWITT, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:DEWITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 GARRETT DR
Mailing Address - Street 2:
Mailing Address - City:PERRYTON
Mailing Address - State:TX
Mailing Address - Zip Code:79070-5323
Mailing Address - Country:US
Mailing Address - Phone:806-435-3606
Mailing Address - Fax:806-435-2067
Practice Address - Street 1:3020 GARRETT DR
Practice Address - Street 2:
Practice Address - City:PERRYTON
Practice Address - State:TX
Practice Address - Zip Code:79070-5322
Practice Address - Country:US
Practice Address - Phone:806-648-9355
Practice Address - Fax:806-228-7071
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4685207Q00000X
ALMD34667207Q00000X
ALL4011R207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program