Provider Demographics
NPI:1306844501
Name:DEWART, MONA RUTH (OD)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:RUTH
Last Name:DEWART
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5014 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6804
Mailing Address - Country:US
Mailing Address - Phone:260-432-4060
Mailing Address - Fax:260-436-7475
Practice Address - Street 1:5014 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6804
Practice Address - Country:US
Practice Address - Phone:260-432-4060
Practice Address - Fax:260-436-7475
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002368B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT84746Medicare UPIN
IN668430Medicare ID - Type Unspecified
IN0129870001Medicare NSC