Provider Demographics
NPI:1609956655
Name:DETWILER, RONALD L (OD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:L
Last Name:DETWILER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3437 W GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-9744
Mailing Address - Country:US
Mailing Address - Phone:330-482-2743
Mailing Address - Fax:
Practice Address - Street 1:15655 STATE ROUTE 170
Practice Address - Street 2:STE. C
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9069
Practice Address - Country:US
Practice Address - Phone:330-385-3895
Practice Address - Fax:330-385-5772
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3166T1622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0324741Medicaid
OHDE0453852Medicare ID - Type Unspecified
OH0324741Medicaid