Basic Information
Provider Information | |||||||||
NPI: | 1225192362 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEWITT | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475462514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8129968478 | ||||||||
FaxNumber: | 8129960214 | ||||||||
Practice Location | |||||||||
Address1: | 800 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | JASPER | ||||||||
State: | IN | ||||||||
PostalCode: | 475462514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8129960323 | ||||||||
FaxNumber: | 8129960321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 09/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 02001330 | IN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 200055720A | 05 | IN |   | MEDICAID | 0000000881030 | 01 | IN | BC ANTHEM ID | OTHER | 02001330 | 01 | IN | INDIANA ID# | OTHER |