=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114960473
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEWITT CHARLES FORTENBERRY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 09/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2602 SAINT MICHAEL DR SUITE 302
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-2387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-336-2391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 WESTLAKE RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501-0006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-293-7093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | L8691
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | L8691
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------