Provider Demographics
NPI:1285623819
Name:DETTWILER, CARL RAY (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:RAY
Last Name:DETTWILER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:PROF
Other - First Name:CARL
Other - Middle Name:RAY
Other - Last Name:DETTWILER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2517 17TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6311
Mailing Address - Country:US
Mailing Address - Phone:208-743-4373
Mailing Address - Fax:208-743-3369
Practice Address - Street 1:2517 17TH SREET
Practice Address - Street 2:SUITE B
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-0001
Practice Address - Country:US
Practice Address - Phone:208-743-4373
Practice Address - Fax:208-743-3369
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806979100Medicaid
1118867Medicare PIN
P00206501Medicare PIN
ID806979100Medicaid