Provider Demographics
NPI:1174642771
Name:DAVID E DETWILER PC
Entity Type:Organization
Organization Name:DAVID E DETWILER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-525-3045
Mailing Address - Street 1:101 PERSIMMON WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1851
Mailing Address - Country:US
Mailing Address - Phone:434-525-3045
Mailing Address - Fax:
Practice Address - Street 1:101 PERSIMMON WAY
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-1851
Practice Address - Country:US
Practice Address - Phone:434-525-3045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000648213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21769Medicare UPIN