Healthcare Provider Details

I. General information

NPI: 1447256136
Provider Name (Legal Business Name): DALE L WITTKOP O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 LOCUST ST
ALLEGAN MI
49010-1301
US

IV. Provider business mailing address

123 LOCUST ST
ALLEGAN MI
49010-1301
US

V. Phone/Fax

Practice location:
  • Phone: 269-673-5100
  • Fax: 269-673-1806
Mailing address:
  • Phone: 269-673-5100
  • Fax: 269-673-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number49010003042
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: