NPIMap

Individual provider Active NPI

Dewitt Charles Fortenberry, MD

  • General Practice Physician
  • Texarkana, TX
National Provider Identifier
1114960473
Registry record updated Sep 17, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
License
L8691 Issued in TX
Practice address
2602 Saint Michael Dr
Suite 302
Texarkana, TX 75503-2387
Phone
(903) 336-2391
NPI assigned
Jun 14, 2006
Last updated
Sep 17, 2023By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Sep 17, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine Physician 207P00000X L8691 TX
General Practice Physician 208D00000X L8691 TX Primary

Addresses

Primary practice location

2602 Saint Michael Dr
Suite 302
Texarkana, TX 75503-2387

Mailing address

116 Westlake Rd
Texarkana, TX 75501-0006
Phone (903) 293-7093

Other practice location 1

4920 Elizabeth St
Texarkana, TX 75503-2912
Phone (903) 792-3812

Other identifiers 1

IdentifierTypeStateIssuer
167594401MedicaidTX

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040812000544 TX Practitioner - Internal MedicinePractitioner - Emergency Medicine 7315919925 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Internal Medicine
Education
Johns Hopkins University School of Medicine, 1990
Medicare assignment
Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

2400 Saint Michael Dr
Texarkana, TX 75503-2374
Phone (903) 293-7093

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Medeval, LLC General Practice CurrentSince Aug 9, 2012 Accepting new patients
Texarkana Emergency Medicine Physicians,PA Emergency Medicine Past Accepting new patients
Pam Squared at Texarkana, LLC Past Accepting new patients
Emergency Associates of Texas, PA Emergency Medicine Past Accepting new patients
Hospital Physician Services, LLLP Past Accepting new patients
Medlantic Healthcare Group Emergency Medicine Past Accepting new patients
Winnie-Stowell Hospital District Past Accepting new patients
Contee Emergency Physicians Emergency Medicine Past Accepting new patients

Locations

1000 Pine St
Texarkana, TX 75501
Phone (903) 798-7365

116 Westlake Rd
Texarkana, TX 75501
Phone (903) 293-7093

2400 Saint Michael Dr
Texarkana, TX 75503
Phone (903) 293-7093

2602 Saint Michael Dr
Ste 302
Texarkana, TX 75503
Phone (903) 293-7093

2900 Saint Michael Dr
Ste 401
Texarkana, TX 75503
Phone (903) 614-5353

4114 McKnight Rd
Texarkana, TX 75503

4920 Elizabeth St
Texarkana, TX 75503
Phone (903) 614-5357

Organizations & group practices 8

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 14

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150243200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1694908800000",
    "number": "1114960473",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "116 WESTLAKE RD",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "755010006",
            "telephone_number": "903-293-7093"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2602 SAINT MICHAEL DR",
            "address_2": "SUITE 302",
            "city": "TEXARKANA",
            "state": "TX",
            "postal_code": "755032387",
            "telephone_number": "903-336-2391"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4920 Elizabeth St",
            "address_purpose": "LOCATION",
            "city": "Texarkana",
            "state": "TX",
            "postal_code": "755032912",
            "country_code": "US",
            "telephone_number": "903-792-3812",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FORTENBERRY",
        "first_name": "DEWITT",
        "middle_name": "CHARLES",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-06-14",
        "last_updated": "2023-09-17",
        "certification_date": "2023-09-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "TX",
            "license": "L8691",
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "TX",
            "license": "L8691",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "167594401",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Texarkana, TX

Sources for this page

Verify at the official NPI Registry.