Provider Demographics
NPI:1972797579
Name:D.C. DEWEESE, P.A.
Entity Type:Organization
Organization Name:D.C. DEWEESE, P.A.
Other - Org Name:NORTHSIDE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:CHRIS
Authorized Official - Last Name:DEWEESE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:904-757-4786
Mailing Address - Street 1:1312 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4836
Mailing Address - Country:US
Mailing Address - Phone:904-757-4786
Mailing Address - Fax:904-757-4882
Practice Address - Street 1:1312 DUNN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4836
Practice Address - Country:US
Practice Address - Phone:904-757-4786
Practice Address - Fax:904-757-4882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8089111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381586200Medicaid
FL381586200Medicaid