Provider Demographics
NPI:1972536274
Name:DETWEILER, DONALD GENE (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:GENE
Last Name:DETWEILER
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 1:1121 SITUS CT STE 170
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4279
Mailing Address - Country:US
Mailing Address - Phone:919-834-2767
Mailing Address - Fax:919-851-4660
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-350-7000
Practice Address - Fax:919-350-8959
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC243782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8928366Medicaid
NC212112Medicare PIN
NC212111Medicare PIN
C87442Medicare UPIN