Provider Demographics
NPI:1700842457
Name:DETLEFS, COREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:L
Last Name:DETLEFS
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 1:1441 N 12TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-521-5968
Mailing Address - Fax:
Practice Address - Street 1:1441 N 12TH ST FL 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-521-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ140179Medicaid
Z122716Medicare PIN
81886Medicare ID - Type Unspecified
AZ140179Medicaid
AZZ111901Medicare PIN
Z119967Medicare PIN
Z74510Medicare PIN
E28364Medicare UPIN