Provider Demographics
NPI:1467421958
Name:DEWITT, COLEEN C (DO)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:C
Last Name:DEWITT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28455 HAGGERTY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2982
Mailing Address - Country:US
Mailing Address - Phone:248-553-2200
Mailing Address - Fax:248-553-2201
Practice Address - Street 1:28455 HAGGERTY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2906
Practice Address - Country:US
Practice Address - Phone:248-553-2200
Practice Address - Fax:248-553-2201
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101013598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4619200Medicaid
N91620038Medicare ID - Type Unspecified
H35800Medicare UPIN