Provider Demographics
NPI:1588151898
Name:DEWYKE, KATHLEEN MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MICHELLE
Last Name:DEWYKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 EAST JERSEY ST
Mailing Address - Street 2:RESIDENCY PROGRAM
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07206
Mailing Address - Country:US
Mailing Address - Phone:908-994-7233
Mailing Address - Fax:
Practice Address - Street 1:654 EAST JERSEY ST
Practice Address - Street 2:RESIDENCY PROGRAM
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07206
Practice Address - Country:US
Practice Address - Phone:908-994-7233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA103262002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty