Provider Demographics
NPI:1043210180
Name:DETWILER BERGER, DAWN M (MD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:M
Last Name:DETWILER BERGER
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 1:2310 CALIFORNIA ROAD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-4163
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:54938 STATE ROAD 13
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-8608
Practice Address - Country:US
Practice Address - Phone:574-825-8685
Practice Address - Fax:574-825-1256
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045293207PE0004X
IN01045293A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200123720Medicaid
IN200123720Medicaid
223420JJJMedicare PIN
IN23220MMMedicare ID - Type Unspecified