Provider Demographics
NPI:1639461932
Name:FOSSITT, DEXTER IV (MD)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:FOSSITT
Suffix:IV
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 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:451 HEALTH PKWY STE F
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-655-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301104615207R00000X
WI57681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine