Provider Demographics
NPI:1558301465
Name:DETTBARN, KYLE JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:JAMES
Last Name:DETTBARN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 OAKWOOD MALL DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-3016
Mailing Address - Country:US
Mailing Address - Phone:715-839-9280
Mailing Address - Fax:
Practice Address - Street 1:3802 OAKWOOD MALL DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3016
Practice Address - Country:US
Practice Address - Phone:715-839-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45848207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34400700Medicaid
WI34400700Medicaid
WIK400138665Medicare PIN