Healthcare Provider Details

I. General information

NPI: 1194706465
Provider Name (Legal Business Name): EDWARD GERARD DETAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 341
COEUR D ALENE ID
83814-4404
US

IV. Provider business mailing address

700 W IRONWOOD DR SUITE 304
COEUR D ALENE ID
83814-2656
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5200
  • Fax: 208-625-5201
Mailing address:
  • Phone: 208-625-5200
  • Fax: 208-625-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-9855
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: