Provider Demographics
NPI:1972557288
Name:DE VITA, JAMAL THOMAS (DC)
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:THOMAS
Last Name:DE VITA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 GREAT RD STE 107
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-5740
Mailing Address - Country:US
Mailing Address - Phone:978-263-9336
Mailing Address - Fax:978-264-4431
Practice Address - Street 1:179 GREAT RD STE 107
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-5740
Practice Address - Country:US
Practice Address - Phone:978-263-9336
Practice Address - Fax:978-264-4431
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1603370Medicaid
MAY45780Medicare ID - Type Unspecified