Provider Demographics
NPI:1073523841
Name:DETER, DWIGHT M (PA-C)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:M
Last Name:DETER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E SCHUSTER AVE
Mailing Address - Street 2:BLDG 7
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4672
Mailing Address - Country:US
Mailing Address - Phone:915-533-5486
Mailing Address - Fax:915-533-9602
Practice Address - Street 1:1201 E SCHUSTER AVE
Practice Address - Street 2:BLDG 7
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4672
Practice Address - Country:US
Practice Address - Phone:915-533-5486
Practice Address - Fax:915-533-9602
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00001207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A3568Medicare ID - Type Unspecified
TXP80361Medicare UPIN