1649222423 NPI number — DEWITT OPTOMETRY PC

Table of content: (NPI 1649222423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649222423 NPI number — DEWITT OPTOMETRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEWITT OPTOMETRY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649222423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12900 S US-27
Provider Second Line Business Mailing Address:
STE #7
Provider Business Mailing Address City Name:
DEWITT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-669-4411
Provider Business Mailing Address Fax Number:
517-669-4433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12900 S US-27
Provider Second Line Business Practice Location Address:
#7
Provider Business Practice Location Address City Name:
DEWITT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-669-4411
Provider Business Practice Location Address Fax Number:
517-669-4411
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CATALINE
Authorized Official First Name:
STACY
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE PATIENT ACCOUNTS
Authorized Official Telephone Number:
517-669-4411

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4901003197 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: JK003635 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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