Provider Demographics
NPI:1780906032
Name:KAREN D DETWILER OD PA
Entity type:Organization
Organization Name:KAREN D DETWILER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-561-5030
Mailing Address - Street 1:410 W TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-1026
Mailing Address - Country:US
Mailing Address - Phone:850-561-5030
Mailing Address - Fax:850-561-0770
Practice Address - Street 1:410 W TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-1026
Practice Address - Country:US
Practice Address - Phone:850-561-5030
Practice Address - Fax:850-561-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1733152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU26562Medicare UPIN
FLCY534AMedicare PIN