Provider Demographics
NPI:1649630435
Name:DEWITT, BARRY (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:DEWITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11345 GREENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2591
Mailing Address - Country:US
Mailing Address - Phone:810-629-3766
Mailing Address - Fax:
Practice Address - Street 1:11345 GREENVIEW DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2591
Practice Address - Country:US
Practice Address - Phone:810-629-3766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035353207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology