Provider Demographics
NPI:1922027242
Name:DETWEILER, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:DETWEILER
Suffix:
Gender:F
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-520-5307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014967207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0247886OtherLABOR & INDUSTRY
WA8270605Medicaid
WAMD967WAOtherALASKA MEDICAID
WAUS0861500OtherAETNA/USHC SPECIALIST
WAPA6985OtherBLUE SHIELD
220024123OtherRAILROAD MEDICARE
A05340Medicare UPIN
220024123OtherRAILROAD MEDICARE