MEDICARE: CRYSTAL A. DE WIT DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	3780	WV
2	207P00000X	Emergency Medicine Physician	3780	WV
3	207Q00000X	Family Medicine Physician	3780	WV
4	207LP2900X	Pain Medicine (Anesthesiology) Physician	3780	WV

General Provider Information

NPI Number	:	1114980406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL A. DE WIT DO

Provider Business Mailing Address
First Line	:	12 ASHBURY LN
Second Line	:
City	:	FAIRMONT
State	:	WV
Zip	:	26554-3473
Country	:	US
Telephone Number	:	412-303-0494
Fax Number	:	412-487-2555

Provider Business Practice Location Address
First Line	:	527 MEDICAL PARK DR STE 500
Second Line	:
City	:	BRIDGEPORT
State	:	WV
Zip	:	26330-9010
Country	:	US
Telephone Number	:	681-342-3600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2006
Last Update Date	:	02/26/2025

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