Provider Demographics
NPI:1669445722
Name:DAETWYLER, EDWARD P (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
Last Name:DAETWYLER
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 1:350 W COLUMBIA ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1782
Mailing Address - Country:US
Mailing Address - Phone:812-425-2646
Mailing Address - Fax:812-467-7209
Practice Address - Street 1:350 W COLUMBIA ST
Practice Address - Street 2:SUITE 310
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1782
Practice Address - Country:US
Practice Address - Phone:812-425-2646
Practice Address - Fax:812-467-7209
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032497A207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100078630Medicaid
IN100078630Medicaid
IN837480BMedicare PIN