Provider Demographics
NPI:1255644225
Name:DEWITT, JEREMIAH J (DO)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:J
Last Name:DEWITT
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 1:1765 3 MILE RD NE UNIT 150319
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49515-5014
Mailing Address - Country:US
Mailing Address - Phone:616-272-3533
Mailing Address - Fax:
Practice Address - Street 1:1765 3 MILE RD NE UNIT 150319
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49515-5014
Practice Address - Country:US
Practice Address - Phone:616-272-3533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019000207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine