Provider Demographics
NPI:1740548346
Name:MEDEVAL, LLC
Entity type:Organization
Organization Name:MEDEVAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEWITT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-641-5512
Mailing Address - Street 1:116 WESTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-0006
Mailing Address - Country:US
Mailing Address - Phone:903-293-7093
Mailing Address - Fax:
Practice Address - Street 1:4920 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2912
Practice Address - Country:US
Practice Address - Phone:903-792-3812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8691208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB164833Medicare PIN