Provider Demographics
NPI:1750373650
Name:DETWILER, LAWRENCE A (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
Last Name:DETWILER
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 1:7575 NORTHCLIFF AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3267
Mailing Address - Country:US
Mailing Address - Phone:216-398-8196
Mailing Address - Fax:216-398-8192
Practice Address - Street 1:7575 NORTHCLIFF AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3267
Practice Address - Country:US
Practice Address - Phone:216-398-8196
Practice Address - Fax:216-398-8192
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-2991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000030812OtherANTHEM BCBS
OH393375OtherWELLCARE OF OH
OHP42991OtherSUMMACARE HEALTH PLAN
OH341847368031OtherCARESOURCE
OH110146704OtherRAILROAD MEDICARE
OH000000030812OtherUNICARE
OH4009105OtherAETNA
OH0517088Medicaid
OH57106OtherTRICARE
OH105347OtherKAISER
OH000000030812OtherUNICARE
OH341847368031OtherCARESOURCE
OHEO4750Medicare UPIN