Basic Information
| Provider Information | |||||||||
| NPI: | 1780906032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KAREN D DETWILER OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 W TENNESSEE ST | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323011026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505615030 | ||||||||
| FaxNumber: | 8505610770 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 W TENNESSEE ST | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323011026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505615030 | ||||||||
| FaxNumber: | 8505610770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2010 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | DETWILER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8505615030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1733 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.