Provider Demographics
NPI:1073601118
Name:ALEX DETWILER, M.D., P.A.
Entity Type:Organization
Organization Name:ALEX DETWILER, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSSON-DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-521-7838
Mailing Address - Street 1:PO BOX 132601
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-2601
Mailing Address - Country:US
Mailing Address - Phone:903-521-7838
Mailing Address - Fax:
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-521-7838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1685174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0056LZOtherBCBS
TXDC1535OtherRAILROAD MEDICARE
TXDC1535OtherRAILROAD MEDICARE