Provider Demographics
NPI:1437121183
Name:ESCONDIDO CARDIOLOGY ASSOCIATES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ESCONDIDO CARDIOLOGY ASSOCIATES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-743-0546
Mailing Address - Street 1:488 E VALLEY PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3363
Mailing Address - Country:US
Mailing Address - Phone:760-743-0546
Mailing Address - Fax:760-743-8837
Practice Address - Street 1:488 E VALLEY PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3363
Practice Address - Country:US
Practice Address - Phone:760-743-0546
Practice Address - Fax:760-743-8837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ70943ZMedicaid
CAZZZ70943ZOtherBLUE SHIELD
CU0135OtherRR MEDICARE
CU0135OtherRR MEDICARE
CAZZZ70943ZMedicaid