1154324036 NPI number — JOHN H DETWILER M.D.

Table of content: JOHN H DETWILER M.D. (NPI 1154324036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154324036 NPI number — JOHN H DETWILER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETWILER
Provider First Name:
JOHN
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154324036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92198-0199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-673-2574
Provider Business Mailing Address Fax Number:
858-618-1523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 W CITRACADO PKWY
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
ESCONDIDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92029-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-743-0546
Provider Business Practice Location Address Fax Number:
760-743-8837
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  G23336 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: G23336 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 060020994 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1154324036 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".