Healthcare Provider Details

I. General information

NPI: 1366474207
Provider Name (Legal Business Name): PAUL R DEWITT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 160 & NAVAJO ROUTE 35 - RED MESA
TEECNOSPOS AZ
86514
US

IV. Provider business mailing address

HC 61 BOX 30
TEEC NOS POS AZ
86514-9600
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5000
  • Fax:
Mailing address:
  • Phone: 928-656-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2320
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: