Individual
DEWITT CHARLES FORTENBERRY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2602 SAINT MICHAEL DR, SUITE 302, TEXARKANA, TX 75503-2387
(903) 336-2391
Mailing address
116 WESTLAKE RD, TEXARKANA, TX 75501-0006
(903) 293-7093
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
L8691
TX
208D00000X
General Practice Physician
Primary
L8691
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
167594401
—
TX
Enumeration date
06/14/2006
Last updated
09/17/2023
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