Provider Demographics
NPI:1487687414
Name:SUSAN P DETWILER MD INC
Entity Type:Organization
Organization Name:SUSAN P DETWILER MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-539-7300
Mailing Address - Street 1:7076 CAMINITO VALVERDE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5723
Mailing Address - Country:US
Mailing Address - Phone:858-539-7300
Mailing Address - Fax:858-539-7305
Practice Address - Street 1:7076 CAMINITO VALVERDE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5723
Practice Address - Country:US
Practice Address - Phone:858-539-7300
Practice Address - Fax:858-539-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75321291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory