Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 8996 | SC |
Y | 1223G0001X | General Practice | 8996 | SC |
Y | 213EG0000X | General Practice | 8996 | SC |
NPI | 1003332784 |
---|---|
Provider Name | Dr. David Matthew Wallitt |
First Address | Fort Sill, OK 73503 |
Second Address | Fort Sill, OK 73503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2017 |
Last Update Date | 20/07/2018 |