Provider Demographics
NPI:1477530210
Name:DETLEFS, RICHARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:DETLEFS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2045 PEACHTREE RD NE STE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1497
Mailing Address - Country:US
Mailing Address - Phone:404-351-7546
Mailing Address - Fax:678-540-0100
Practice Address - Street 1:2045 PEACHTREE RD NE
Practice Address - Street 2:SUITE 525
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1414
Practice Address - Country:US
Practice Address - Phone:404-351-7546
Practice Address - Fax:678-540-0100
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA29438207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA070004456OtherRAILROAD MEDICARE
GA481059OtherAETNA
GA0307080OtherUNITED HEALTHCARE
GA07BDBFGMedicare ID - Type Unspecified
GA0307080OtherUNITED HEALTHCARE