Provider Demographics
NPI:1811051816
Name:PREWITT, P. VANCE (MD)
Entity type:Individual
Prefix:
First Name:P.
Middle Name:VANCE
Last Name:PREWITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRO
Other - Middle Name:V
Other - Last Name:PREWITT
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:402 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:DE
Mailing Address - Zip Code:19956-1552
Mailing Address - Country:US
Mailing Address - Phone:302-875-4411
Mailing Address - Fax:
Practice Address - Street 1:402 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:DE
Practice Address - Zip Code:19956-1552
Practice Address - Country:US
Practice Address - Phone:302-875-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1811051816Medicaid
DE1811051816Medicaid
DE156382Medicare PIN