Provider Demographics
NPI:1184656290
Name:DETWILER, SUSAN P (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:DETWILER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7076 CAMINITO VALVERDE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5723
Mailing Address - Country:US
Mailing Address - Phone:858-539-7300
Mailing Address - Fax:858-539-7305
Practice Address - Street 1:7110 CAMINITO PEPINO
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5721
Practice Address - Country:US
Practice Address - Phone:858-539-7300
Practice Address - Fax:858-539-7305
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75321207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G753212Medicaid
CA00G753213OtherBLUE SHIELD OF CA
CA00G753214OtherBLUE SHIELD OF CA
CA070017499OtherMEDICARE RAILROAD
CALAB25100FMedicaid
CA00G753214OtherBLUE SHIELD OF CA
CAG17383Medicare UPIN
CAHG75321Medicare ID - Type UnspecifiedDERMATOLOGY