Basic Information
| Provider Information | |||||||||
| NPI: | 1659522324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEWITT | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 S HAGADORN RD | ||||||||
| Address2: | #500 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178844554 | ||||||||
| FaxNumber: | 5178844556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | OS014230 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XP3100X | 5101019945 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1659522324 | 05 | MI | MEDICAID |