Provider Demographics
NPI:1447256136
Name:WITTKOP, DALE L (OD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:L
Last Name:WITTKOP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1301
Mailing Address - Country:US
Mailing Address - Phone:269-673-5100
Mailing Address - Fax:269-673-1806
Practice Address - Street 1:123 LOCUST ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1301
Practice Address - Country:US
Practice Address - Phone:269-673-5100
Practice Address - Fax:269-673-1806
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI49010003042152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
900Z310140OtherBCBS OF MICHIGAN
MI900Z365250OtherBCBS OF MICHIGAN
MI944193774Medicaid
MI900Z365250OtherBCBS OF MICHIGAN
900Z310140OtherBCBS OF MICHIGAN