Provider Demographics
NPI:1053753137
Name:DEWITT, DEREK W (DO)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:W
Last Name:DEWITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3487 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7213
Mailing Address - Country:US
Mailing Address - Phone:239-334-9555
Mailing Address - Fax:239-334-2832
Practice Address - Street 1:3487 BROADWAY AVENUE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7213
Practice Address - Country:US
Practice Address - Phone:239-334-9555
Practice Address - Fax:239-334-2832
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008586207Q00000X, 207Q00000X
FLOS12842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine