Provider Demographics
NPI:1346285210
Name:DEWEY, COURTNEY AMANDA (OD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:AMANDA
Last Name:DEWEY
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 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1000 WALL ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-1912
Practice Address - Country:US
Practice Address - Phone:734-764-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004281152W00000X
OH5381152W00000X
OH5381 T2292152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4878355Medicaid
OH2428813Medicaid
OH9310794Medicare PIN
OHU97196Medicare UPIN
MIN14190011Medicare PIN
OH9310791Medicare PIN
OH2428813Medicaid
P00373573Medicare PIN
OH4118722Medicare PIN
OH9310793Medicare PIN