Provider Demographics
NPI:1225192362
Name:DEWITT, STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:DEWITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-2514
Mailing Address - Country:US
Mailing Address - Phone:812-996-8478
Mailing Address - Fax:812-996-0214
Practice Address - Street 1:800 W 9TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2514
Practice Address - Country:US
Practice Address - Phone:812-996-0323
Practice Address - Fax:812-996-0321
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001330207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200055720AMedicaid
IN0000000881030OtherBC ANTHEM ID
IN02001330OtherINDIANA ID#
INE64667Medicare UPIN