Provider Demographics
NPI:1326319724
Name:DETTMER, ROBERT WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:DETTMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:2935 AMBLESIDE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2443
Mailing Address - Country:US
Mailing Address - Phone:260-459-7657
Mailing Address - Fax:260-459-7658
Practice Address - Street 1:2935 AMBLESIDE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2443
Practice Address - Country:US
Practice Address - Phone:260-459-7657
Practice Address - Fax:260-459-7658
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01022140A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology