Provider Demographics
NPI:1003280298
Name:DETTMANN, FREDERICK GUSTAV (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:GUSTAV
Last Name:DETTMANN
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 1:4801 N 68TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-1143
Mailing Address - Country:US
Mailing Address - Phone:480-481-3076
Mailing Address - Fax:480-481-9208
Practice Address - Street 1:4801 N 68TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-1143
Practice Address - Country:US
Practice Address - Phone:480-481-3076
Practice Address - Fax:480-481-9208
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25333261QA0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility