Provider Demographics
NPI:1346227477
Name:DETERS, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:DETERS
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:PO BOX 2880
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2880
Mailing Address - Country:US
Mailing Address - Phone:319-272-2152
Mailing Address - Fax:319-272-2038
Practice Address - Street 1:1443 PROSPECT BLVD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4953
Practice Address - Country:US
Practice Address - Phone:319-234-6553
Practice Address - Fax:319-272-2038
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19538207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0128801Medicaid
IA110115799OtherRR MEDICARE
IA53299Medicare PIN
IAA01137Medicare UPIN