Provider Demographics
NPI:1154364024
Name:DETWILER, JAMES K (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:K
Last Name:DETWILER
Suffix:
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:PO BOX 1420
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0400
Mailing Address - Country:US
Mailing Address - Phone:541-548-2164
Mailing Address - Fax:541-548-0534
Practice Address - Street 1:211 NW LARCH AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1357
Practice Address - Country:US
Practice Address - Phone:541-548-2164
Practice Address - Fax:541-548-0534
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09568207Q00000X, 207QG0300X, 2083A0100X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11129522OtherCAQH ID
OR233692Medicaid
OR233692Medicaid