Provider Demographics
NPI:1912949850
Name:DETWILER, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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:PO BOX 45680
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145-0680
Mailing Address - Country:US
Mailing Address - Phone:530-626-3682
Mailing Address - Fax:
Practice Address - Street 1:1095 MARSHALL WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5722
Practice Address - Country:US
Practice Address - Phone:530-626-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31263208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFQ337ZMedicare PIN