Provider Demographics
NPI:1639596091
Name:JT DEWITT D.O.P.A.
Entity type:Organization
Organization Name:JT DEWITT D.O.P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:870-897-8433
Mailing Address - Street 1:3071 HIGHWAY 34 E
Mailing Address - Street 2:
Mailing Address - City:MARMADUKE
Mailing Address - State:AR
Mailing Address - Zip Code:72443-9773
Mailing Address - Country:US
Mailing Address - Phone:870-897-8433
Mailing Address - Fax:870-897-8438
Practice Address - Street 1:11998 HIGHWAY 49 N
Practice Address - Street 2:
Practice Address - City:MARMADUKE
Practice Address - State:AR
Practice Address - Zip Code:72443-9597
Practice Address - Country:US
Practice Address - Phone:870-897-8433
Practice Address - Fax:870-897-8438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4975261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175408003Medicaid