Provider Demographics
NPI:1396822482
Name:COREY L DETLEFS MD
Entity Type:Organization
Organization Name:COREY L DETLEFS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DETLEFS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-340-0201
Mailing Address - Street 1:2320 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1303
Mailing Address - Country:US
Mailing Address - Phone:602-340-0201
Mailing Address - Fax:602-441-5115
Practice Address - Street 1:2320 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1303
Practice Address - Country:US
Practice Address - Phone:602-340-0201
Practice Address - Fax:602-441-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ140179Medicaid
AZ140179Medicaid
AZE28364Medicare UPIN