Provider Demographics
NPI:1740244193
Name:DEW, JOHN S (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:DEW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:819 S. 13TH STREET
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-814-6230
Practice Address - Fax:360-814-6240
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010625204D00000X, 207Q00000X
WAOP60640808204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740244193Medicaid
MI08-5-41-0248-5OtherBCBS PIN
MI1740244193Medicaid
MIM53750050Medicare PIN