Provider Demographics
NPI:1306897970
Name:DETAR, JOSEPHINE (MD)
Entity type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:DETAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 WOODS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:MILLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14864-9730
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:
Practice Address - Street 1:1927 WOODS EDGE DR
Practice Address - Street 2:
Practice Address - City:MILLPORT
Practice Address - State:NY
Practice Address - Zip Code:14864-9730
Practice Address - Country:US
Practice Address - Phone:800-394-4445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1867691207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018396300001Medicaid
NY050084782OtherRR MEDICARE
NY610421800OtherDEPT OF LABOR
NY008130315OtherBCBS
NY01390312Medicaid
PA0018396300001Medicaid