Basic Information
| Provider Information | |||||||||
| NPI: | 1245400571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEWITT | ||||||||
| FirstName: | JOE-LA | ||||||||
| MiddleName: | DANIELE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836828 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | HANCOCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831050 | ||||||||
| FaxNumber: | 9063723230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101016130 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1245400571 | 05 | MI | MEDICAID |