Provider Demographics
NPI:1124478581
Name:DEWIT, MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEWIT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 N CASS ST
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1613
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:13197 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18003973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201367130Medicaid
IN544150022Medicare PIN