Healthcare Provider Details

I. General information

NPI: 1750589727
Provider Name (Legal Business Name): TODD DETTMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNM DEPT OF EMERGENCY MEDICINE MSC11 6025 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

5605 N MACARTHUR BLVD STE 740
IRVING TX
75038-2626
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5062
  • Fax: 505-272-6503
Mailing address:
  • Phone: 214-960-5681
  • Fax: 214-960-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberMD2010-0476
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberAB7003469-B439
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License NumberW1154
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD 60152927
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberAB7003469-B439
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD2010-0476
License Number StateNM
# 7
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberW1154
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: