Provider Demographics
NPI:1194706465
Name:DETAR, EDWARD GERARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GERARD
Last Name:DETAR
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-625-5200
Mailing Address - Fax:208-625-5201
Practice Address - Street 1:700 W IRONWOOD DR STE 341
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4404
Practice Address - Country:US
Practice Address - Phone:208-625-5200
Practice Address - Fax:208-625-5201
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9855208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID77068OtherBC ID
IDP00448097OtherRR MEDICARE
ID807836200Medicaid
WA1124619Medicaid
WA1124619Medicaid
IDP00448097OtherRR MEDICARE