Basic Information
| Provider Information | |||||||||
| NPI: | 1306478417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DTM WELLNESS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 SHELLEY PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757019457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729206968 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 SHELLEY PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757019457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729206968 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2020 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | DEREK | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9729206968 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.