Provider Demographics
NPI:1700853033
Name:DETWILER, KAREN DORA (OD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:DORA
Last Name:DETWILER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-1026
Mailing Address - Country:US
Mailing Address - Phone:850-561-5030
Mailing Address - Fax:850-561-0770
Practice Address - Street 1:410 W TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-1026
Practice Address - Country:US
Practice Address - Phone:850-561-5030
Practice Address - Fax:850-561-0770
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-06
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078234300Medicaid
FL19581YMedicare PIN
FLU26562Medicare UPIN