Provider Demographics
NPI:1841240686
Name:DETLIE, TORE (MD)
Entity Type:Individual
Prefix:DR
First Name:TORE
Middle Name:
Last Name:DETLIE
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 1:11995 SINGLETREE LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:918 DEMONT AVE E
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1953
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN295462085R0202X
NH154352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology