Provider Demographics
NPI:1144326679
Name:DEWEESE, PAUL N (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:N
Last Name:DEWEESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 BELLE CHASE WAY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4282
Mailing Address - Country:US
Mailing Address - Phone:517-999-9020
Mailing Address - Fax:517-999-0096
Practice Address - Street 1:3410 BELLE CHASE WAY
Practice Address - Street 2:STE 600
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4274
Practice Address - Country:US
Practice Address - Phone:517-999-9020
Practice Address - Fax:517-999-0096
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPD044882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104833729Medicaid
MI104833729Medicaid
MI0P19950Medicare ID - Type Unspecified