MEDICARE: BRIAN DOUGLAS DEWITT D.O.

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	208000000X	Pediatrics Physician	UO3432	FL

General Provider Information

NPI Number	:	1841627049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN DOUGLAS DEWITT D.O.

Provider Business Mailing Address
First Line	:	21321 E OCOTILLO RD STE 110
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-5993
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21321 E OCOTILLO RD STE 110
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-5993
Country	:	US
Telephone Number	:	480-677-4545
Fax Number	:

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

Provider Enumeration Date	:	10/02/2013
Last Update Date	:	08/24/2021

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