Provider Demographics
NPI:1649222423
Name:DEWITT OPTOMETRY PC
Entity Type:Organization
Organization Name:DEWITT OPTOMETRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE PATIENT ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CATALINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-669-4411
Mailing Address - Street 1:12900 S US-27
Mailing Address - Street 2:STE #7
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820
Mailing Address - Country:US
Mailing Address - Phone:517-669-4411
Mailing Address - Fax:517-669-4433
Practice Address - Street 1:12900 S US-27
Practice Address - Street 2:#7
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820
Practice Address - Country:US
Practice Address - Phone:517-669-4411
Practice Address - Fax:517-669-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003197152W00000X
MIJK003635152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1272120001Medicare NSC