Provider Demographics
NPI:1154331155
Name:EHLING, DETLEF K (MD)
Entity Type:Individual
Prefix:DR
First Name:DETLEF
Middle Name:K
Last Name:EHLING
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 1:2485 HIGH SCHOOL AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1819
Mailing Address - Country:US
Mailing Address - Phone:925-682-0390
Mailing Address - Fax:925-682-0391
Practice Address - Street 1:2485 HIGH SCHOOL AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1819
Practice Address - Country:US
Practice Address - Phone:925-682-0390
Practice Address - Fax:925-682-0391
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACNC 3005001Medicaid
CACNC 3005001Medicaid
CA05D0597821Medicare ID - Type UnspecifiedMEDICARE PROVIDER #