Healthcare Provider Details

I. General information

NPI: 1285623819
Provider Name (Legal Business Name): CARL RAY DETTWILER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CARL RAY DETTWILER M.D.

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2517 17TH SREET SUITE B
LEWISTON ID
83501-0001
US

IV. Provider business mailing address

2517 17TH ST SUITE B
LEWISTON ID
83501-6311
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-4373
  • Fax: 208-743-3369
Mailing address:
  • Phone: 208-743-4373
  • Fax: 208-743-3369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM5110
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: