Healthcare Provider Details

I. General information

NPI: 1184656290
Provider Name (Legal Business Name): SUSAN P DETWILER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7110 CAMINITO PEPINO
LA JOLLA CA
92037-5721
US

IV. Provider business mailing address

7076 CAMINITO VALVERDE
LA JOLLA CA
92037-5723
US

V. Phone/Fax

Practice location:
  • Phone: 858-539-7300
  • Fax: 858-539-7305
Mailing address:
  • Phone: 858-539-7300
  • Fax: 858-539-7305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG75321
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG75321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: