MEDICARE: MARK KENNETH DETWEILER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	6919	NH
2	174400000X	Specialist	6919	NH

General Provider Information

NPI Number	:	1548344583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK KENNETH DETWEILER M.D.

Provider Business Mailing Address
First Line	:	1B COMMONS DR
Second Line	:	UNIT 9A
City	:	LONDONDERRY
State	:	NH
Zip	:	03053-3441
Country	:	US
Telephone Number	:	603-818-4712
Fax Number	:	603-421-6899

Provider Business Practice Location Address
First Line	:	1B COMMONS DR
Second Line	:	UNIT 9A
City	:	LONDONDERRY
State	:	NH
Zip	:	03053-3441
Country	:	US
Telephone Number	:	603-818-4712
Fax Number	:	603-421-6899

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	04/24/2019

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