Healthcare Provider Details

I. General information

NPI: 1053753137
Provider Name (Legal Business Name): DEREK W. DEWITT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3487 BROADWAY AVENUE
FORT MYERS FL
33901-7213
US

IV. Provider business mailing address

3487 BROADWAY
FORT MYERS FL
33901-7213
US

V. Phone/Fax

Practice location:
  • Phone: 239-334-9555
  • Fax: 239-334-2832
Mailing address:
  • Phone: 239-334-9555
  • Fax: 239-334-2832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number008586
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS12842
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: