Basic Information
| Provider Information | |||||||||
| NPI: | 1346285210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWEY | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | AMANDA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 WALL ST | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481051912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347644190 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
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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 | 152W00000X | 4901004281 | MI | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 5381 | OH | N | Eye and Vision Services Providers | Optometrist | 152WP0200X | 5381 T2292 | OH | N | Eye and Vision Services Providers | Optometrist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4878355 | 05 | MI | MEDICAID | 2428813 | 05 | OH | MEDICAID |