Healthcare Provider Details

I. General information

NPI: 1285658989
Provider Name (Legal Business Name): RAYMOND DATTWYLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 PARK AVE
HUNTINGTON NY
11743-2779
US

IV. Provider business mailing address

325 PARK AVE
HUNTINGTON NY
11743-2779
US

V. Phone/Fax

Practice location:
  • Phone: 631-659-4491
  • Fax: 631-659-4580
Mailing address:
  • Phone: 631-659-4491
  • Fax: 631-659-4580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number145814
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: