Provider Demographics
NPI:1548262702
Name:DEWALD, MARILYNN S (MD)
Entity type:Individual
Prefix:DR
First Name:MARILYNN
Middle Name:S
Last Name:DEWALD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1978
Mailing Address - Country:US
Mailing Address - Phone:906-487-1710
Mailing Address - Fax:906-487-9421
Practice Address - Street 1:1000 CEDAR ST
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1978
Practice Address - Country:US
Practice Address - Phone:906-487-1710
Practice Address - Fax:906-487-9421
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI233857OtherRHC MEDICARE NUMBER
MI4301056759OtherMI LICENSE NUMBER
MI2668377Medicaid
MI2668377Medicaid
MI233857OtherRHC MEDICARE NUMBER
MI0C16034Medicare ID - Type UnspecifiedMEDICARE NUMBER