Provider Demographics
NPI:1043406721
Name:DR. RONALD L. DETWILER, O.D. INC.
Entity Type:Organization
Organization Name:DR. RONALD L. DETWILER, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-385-3898
Mailing Address - Street 1:15655 STATE ROUTE 170
Mailing Address - Street 2:SUITE C
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-9069
Mailing Address - Country:US
Mailing Address - Phone:330-385-3898
Mailing Address - Fax:330-385-5772
Practice Address - Street 1:15655 STATE RT 170
Practice Address - Street 2:SUITE C
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9069
Practice Address - Country:US
Practice Address - Phone:330-385-3898
Practice Address - Fax:330-385-5772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
OH3166 T1622332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0324741Medicaid
DE0453852Medicare PIN
OHT46977Medicare UPIN
OH0324741Medicaid