1184656290 NPI number — SUSAN P DETWILER MD

Table of content: SUSAN P DETWILER MD (NPI 1184656290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184656290 NPI number — SUSAN P DETWILER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETWILER
Provider First Name:
SUSAN
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1184656290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7076 CAMINITO VALVERDE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-5723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-539-7300
Provider Business Mailing Address Fax Number:
858-539-7305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7110 CAMINITO PEPINO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-5721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-539-7300
Provider Business Practice Location Address Fax Number:
858-539-7305
Provider Enumeration Date:
07/07/2006

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: 207N00000X , with the licence number:  G75321 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ND0900X , with the licence number: G75321 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G753212 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G753213 . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G753214 . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 070017499 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LAB25100F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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