Provider Demographics
NPI:1508886516
Name:ERDMANN, DETLEV (MD,PHD,MHSC)
Entity Type:Individual
Prefix:MR
First Name:DETLEV
Middle Name:
Last Name:ERDMANN
Suffix:
Gender:M
Credentials:MD,PHD,MHSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MEDICINE CIRCLE DUMC BOX 3181
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27710-4000
Mailing Address - Country:US
Mailing Address - Phone:919-681-4656
Mailing Address - Fax:
Practice Address - Street 1:40 MEDICINE CIRCLE BROWN ZONE BAKER HOUSE ROOM 133
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:191-968-4332
Practice Address - Fax:919-681-2670
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00852208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200108508Medicaid