Provider Demographics
NPI:1801960539
Name:DEWITT, BRENT (DC)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
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 1:2309 W WHITE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7421
Mailing Address - Country:US
Mailing Address - Phone:217-787-8188
Mailing Address - Fax:217-787-8190
Practice Address - Street 1:2309 W WHITE OAKS DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7421
Practice Address - Country:US
Practice Address - Phone:217-787-8188
Practice Address - Fax:217-787-8190
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT37815Medicare UPIN
IL683430Medicare ID - Type Unspecified