=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013987262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN DEWEBER MD, FAMSSM, FAAFP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2006
-----------------------------------------------------
Last Update Date | 04/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E. 33RD STREET FAMILY MEDICINE OF SW WASHINGTON
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-514-7550
-----------------------------------------------------
Fax | 360-514-7494
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | FAMILY MEDICINE OF SW WASHINGTON 100 EAST 33RD STREET SUITE 100
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-514-7550
-----------------------------------------------------
Fax | 360-514-7484
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | MD60291290
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------