Provider Demographics
NPI:1154324036
Name:DETWILER, JOHN H (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:H
Last Name:DETWILER
Suffix:
Gender:M
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:PO BOX 28199
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0199
Mailing Address - Country:US
Mailing Address - Phone:858-673-2574
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:1955 W CITRACADO PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4113
Practice Address - Country:US
Practice Address - Phone:760-743-0546
Practice Address - Fax:760-743-8837
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23336207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
060020994OtherRR MEDICARE
CA1154324036Medicaid
CAWG23336AMedicare PIN
CAWG23336CMedicare PIN
060020994OtherRR MEDICARE