Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD09568 | OR |
N | 207QG0300X | Family Doctor - Geriatric Medicine | MD09568 | OR |
NPI | 1154364024 |
---|---|
Provider Name | James K Detwiler |
First Address | Redmond, OR 97756-0400 |
Second Address | Redmond, OR 97756-1357 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 07/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
11129522 | CAQH ID (01) | OR |
233692 | (05) | OR |