Provider Demographics
NPI:1700882396
Name:DEWITT, MATTHEW T (DPM)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:T
Last Name:DEWITT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-2150
Mailing Address - Country:US
Mailing Address - Phone:765-284-3879
Mailing Address - Fax:
Practice Address - Street 1:2106 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2150
Practice Address - Country:US
Practice Address - Phone:765-284-3879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000971A213ES0103X
IN07000917A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300022448Medicaid
IN100106820OtherCENTRAL INDIANA ORTHOPEDICS, PC
IN200472410Medicaid
IN5531780001OtherDME
IN000000378808OtherBLUE CROSS/BLUE SHIELD
IN232470AMedicare PIN
IN000000378808OtherBLUE CROSS/BLUE SHIELD