Provider Demographics
NPI:1790751246
Name:DETWEILER, ROBERT O (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:O
Last Name:DETWEILER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 NORTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446
Mailing Address - Country:US
Mailing Address - Phone:215-368-1900
Mailing Address - Fax:215-368-8772
Practice Address - Street 1:1970 NORTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1002
Practice Address - Country:US
Practice Address - Phone:215-368-1900
Practice Address - Fax:215-368-8772
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005844L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA129258101Medicaid
PA129258101Medicaid
B40432Medicare UPIN