Provider Demographics
NPI:1154303923
Name:DETWEILER III, EDWIN (OD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:DETWEILER III
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6002 POINTE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5531
Mailing Address - Country:US
Mailing Address - Phone:941-792-2020
Mailing Address - Fax:941-782-1089
Practice Address - Street 1:6002 POINTE WEST BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5531
Practice Address - Country:US
Practice Address - Phone:941-792-2020
Practice Address - Fax:941-782-1089
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621086400Medicaid
FLU6256ZMedicare PIN
FL621086400Medicaid