Provider Demographics
NPI:1649404195
Name:DETRES, JAVIETH H (MD)
Entity type:Individual
Prefix:
First Name:JAVIETH
Middle Name:H
Last Name:DETRES
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9150 MERIDIAN DR E
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33076-4612
Mailing Address - Country:US
Mailing Address - Phone:787-240-4646
Mailing Address - Fax:
Practice Address - Street 1:4850 W OAKLAND PARK BLVD STE 136
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7277
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:877-762-0841
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL140765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRGQ436AMedicare PIN