Healthcare Provider Details

I. General information

NPI: 1841627049
Provider Name (Legal Business Name): BRIAN DOUGLAS DEWITT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 E OCOTILLO RD STE 110
QUEEN CREEK AZ
85142-5993
US

IV. Provider business mailing address

21321 E OCOTILLO RD STE 110
QUEEN CREEK AZ
85142-5993
US

V. Phone/Fax

Practice location:
  • Phone: 480-677-4545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberUO3432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: