Provider Demographics
NPI:1356395651
Name:DE VITA, THOMAS RICHARD (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:RICHARD
Last Name:DE VITA
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:PO BOX 2705
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-6705
Mailing Address - Country:US
Mailing Address - Phone:978-263-9336
Mailing Address - Fax:978-264-4431
Practice Address - Street 1:271 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4772
Practice Address - Country:US
Practice Address - Phone:978-263-9336
Practice Address - Fax:978-264-4431
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1603698Medicaid
MAT58061Medicare UPIN
MA1603698Medicaid