Provider Demographics
NPI:1245328145
Name:DEWITT, WARREN (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:DEWITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:SUSQUEHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18847-1611
Mailing Address - Country:US
Mailing Address - Phone:570-853-3995
Mailing Address - Fax:570-853-3728
Practice Address - Street 1:401 BROAD AVE
Practice Address - Street 2:
Practice Address - City:SUSQUEHANNA
Practice Address - State:PA
Practice Address - Zip Code:18847-1611
Practice Address - Country:US
Practice Address - Phone:570-853-3995
Practice Address - Fax:570-853-3728
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024723E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00008041930008Medicaid
C31153Medicare UPIN
PA00008041930008Medicaid