Provider Demographics
NPI:1285658989
Name:DATTWYLER, RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:DATTWYLER
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 1:325 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2779
Mailing Address - Country:US
Mailing Address - Phone:631-659-4491
Mailing Address - Fax:631-659-4580
Practice Address - Street 1:325 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2779
Practice Address - Country:US
Practice Address - Phone:631-659-4491
Practice Address - Fax:631-659-4580
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY145814207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000090207OtherGHI HMO
NY00662840Medicaid
145814OtherHIP
NY4589993OtherAETNA PPO
P3453285OtherOXFORD
NY3738401OtherAETNA HMO
NY389284OtherMVP
133277785OtherTRICARE
NY2099746OtherGHI PPO
DR5814OtherATLANTIS
NY3C7116OtherHEALTHNET
NY145814OtherHIP
NY00662840Medicaid