Provider Demographics
NPI:1982468047
Name:DEWITT, KENNETH WAYNE
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:DEWITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417759 EAST 1116 RD
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426
Mailing Address - Country:US
Mailing Address - Phone:405-493-5654
Mailing Address - Fax:
Practice Address - Street 1:417759 EAST 1116 RD
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426
Practice Address - Country:US
Practice Address - Phone:405-493-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist