Provider Demographics
NPI:1215955950
Name:DETWEILER, JEFFREY GASTON (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:GASTON
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 1:1355 RIVER BEND DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:214-638-2000
Mailing Address - Fax:214-237-1864
Practice Address - Street 1:6100 HARRIS PARKWAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4126
Practice Address - Country:US
Practice Address - Phone:214-638-2000
Practice Address - Fax:214-237-1864
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5867207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220018477OtherRAILROAD MEDICARE
TX83P494OtherBCBS
TX132426106Medicaid
TX83P494Medicare ID - Type UnspecifiedLOCALITY 28
TX83P494OtherBCBS