MEDICARE: DEWITT CHARLES FORTENBERRY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	L8691	TX
2	208D00000X	General Practice Physician	L8691	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114960473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEWITT CHARLES FORTENBERRY MD

Provider Business Mailing Address
First Line	:	116 WESTLAKE RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75501-0006
Country	:	US
Telephone Number	:	903-293-7093
Fax Number	:

Provider Business Practice Location Address
First Line	:	2602 SAINT MICHAEL DR
Second Line	:	SUITE 302
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2387
Country	:	US
Telephone Number	:	903-336-2391
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	09/17/2023

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