Provider Demographics
NPI:1700855475
Name:DEW, ANTJE SOUTHWICK (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTJE
Middle Name:SOUTHWICK
Last Name:DEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1900 TIMBER RIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9359
Mailing Address - Country:US
Mailing Address - Phone:616-682-2045
Mailing Address - Fax:
Practice Address - Street 1:3152 PORT SHELDON ST
Practice Address - Street 2:SUITE C
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9297
Practice Address - Country:US
Practice Address - Phone:616-669-9238
Practice Address - Fax:616-669-8296
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301078492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I22687Medicare UPIN