Provider Demographics
NPI:1013151638
Name:DEWITT, BRADFORD JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:JOSEPH
Last Name:DEWITT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15465 OAK LN STE 100B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2663
Mailing Address - Country:US
Mailing Address - Phone:228-832-0846
Mailing Address - Fax:228-832-0856
Practice Address - Street 1:15465 OAK LN STE 100B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2663
Practice Address - Country:US
Practice Address - Phone:228-832-0846
Practice Address - Fax:228-832-0856
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor