Provider Demographics
NPI:1689846552
Name:DETLEF EHLING MD, INC.
Entity Type:Organization
Organization Name:DETLEF EHLING MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DETLEF
Authorized Official - Middle Name:
Authorized Official - Last Name:EHLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-682-0390
Mailing Address - Street 1:2485 HIGH SCHOOL AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1819
Mailing Address - Country:US
Mailing Address - Phone:925-682-0390
Mailing Address - Fax:925-682-0391
Practice Address - Street 1:2485 HIGH SCHOOL AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1819
Practice Address - Country:US
Practice Address - Phone:925-682-0390
Practice Address - Fax:925-682-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66608261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACNC 3005001Medicaid
CACNC 3005001Medicaid