Provider Demographics
NPI:1033229935
Name:DETTEN, WILLIAM RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RUSSELL
Last Name:DETTEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-1362
Mailing Address - Fax:417-269-1372
Practice Address - Street 1:1530 E REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6530
Practice Address - Country:US
Practice Address - Phone:417-269-1362
Practice Address - Fax:417-269-1372
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4P90207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO246778419Medicaid
5716OtherBLUE CROSS MO
917185132Medicare PIN
F29291Medicare UPIN
004012299Medicare PIN
5716OtherBLUE CROSS MO
080072355Medicare PIN