Basic Information
| Provider Information | |||||||||
| NPI: | 1114044476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETTLOFF | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DR | ||||||||
| Address2: | SUITE 1200W | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723648000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1830 JARVIS AVE | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600072440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157784066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0500X | 036-086013 | IL | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.