Provider Demographics
NPI:1417479718
Name:DEWITT, ELYSE (OD)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:DEWITT
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 1:109 RESIDENCES LN APT 411
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7995
Mailing Address - Country:US
Mailing Address - Phone:619-890-6902
Mailing Address - Fax:
Practice Address - Street 1:1470 TOBIAS GADSON BLVD STE 115
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4835
Practice Address - Country:US
Practice Address - Phone:843-556-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2017-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1998152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy