Provider Demographics
NPI:1881753689
Name:DEWITT, TANYA S (MD)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:S
Last Name:DEWITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 THOMAS JOHNSON DRIVE
Mailing Address - Street 2:SUITE J
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4895
Mailing Address - Country:US
Mailing Address - Phone:301-620-0010
Mailing Address - Fax:301-682-3977
Practice Address - Street 1:75 THOMAS JOHNSON DRIVE
Practice Address - Street 2:SUITE J
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4895
Practice Address - Country:US
Practice Address - Phone:301-620-0010
Practice Address - Fax:301-682-3977
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA233739207V00000X
NH10361207V00000X
VT8398207V00000X
MDD33419207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2144557Medicaid
NH30011547Medicaid
MD1497862DDOMedicare PIN
NHRE4901Medicare ID - Type Unspecified
MAF08105Medicare UPIN
MA2144557Medicaid