Basic Information
| Provider Information | |||||||||
| NPI: | 1194706465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETAR | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | GERARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W IRONWOOD DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255200 | ||||||||
| FaxNumber: | 2086255201 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W IRONWOOD DR STE 341 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255200 | ||||||||
| FaxNumber: | 2086255201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | M-9855 | ID | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00448097 | 01 | ID | RR MEDICARE | OTHER | 1124619 | 05 | WA | MEDICAID | 807836200 | 05 | ID | MEDICAID | 77068 | 01 | ID | BC ID | OTHER |