Provider Demographics
NPI:1740260330
Name:JEWETT, DENNIS A (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:A
Last Name:JEWETT
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 1:601 JOHN ST
Mailing Address - Street 2:SUITE M124
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7500
Mailing Address - Fax:269-341-7540
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M124
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:269-341-7540
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010364952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2602070Medicaid
MICK6240OtherRAILROAD MEDICARE
MI2602070Medicaid
MI0C97618064Medicare PIN