Provider Demographics
NPI:1568881076
Name:DTRC, LLC
Entity Type:Organization
Organization Name:DTRC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:DEWESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-807-0247
Mailing Address - Street 1:6447 S EAST ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2118
Mailing Address - Country:US
Mailing Address - Phone:317-807-0247
Mailing Address - Fax:317-735-1951
Practice Address - Street 1:6447 S EAST ST
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2118
Practice Address - Country:US
Practice Address - Phone:317-807-0247
Practice Address - Fax:317-735-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036126A207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty