Provider Demographics
NPI:1316093180
Name:DETTERLINE, ALVIN J IV (MD)
Entity type:Individual
Prefix:DR
First Name:ALVIN
Middle Name:J
Last Name:DETTERLINE
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:8322 BELLONA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2065
Mailing Address - Country:US
Mailing Address - Phone:410-337-7900
Mailing Address - Fax:410-821-1334
Practice Address - Street 1:8322 BELLONA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2065
Practice Address - Country:US
Practice Address - Phone:410-337-7900
Practice Address - Fax:410-821-1334
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-11-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35-088976174400000X
MDD0067412207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D0067412OtherMARYLAND BOP LICENSE