MEDICARE: OWEN C. DEWITT, MD

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	174400000X	Specialist	G3287	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DD3512	OTHER	TX	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1801075619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OWEN C. DEWITT, MD

Provider Business Mailing Address
First Line	:	PO BOX 11128
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-0128
Country	:	US
Telephone Number	:	817-336-1071
Fax Number	:	817-546-8681

Provider Business Practice Location Address
First Line	:	1307 8TH AVE STE 603
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4142
Country	:	US
Telephone Number	:	817-336-1071
Fax Number	:	817-546-8681

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	OWEN C. DEWITT
Credential	:	MD
Telephone Number	:	817-336-1071

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	02/22/2008

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