Healthcare Provider Details

I. General information

NPI: 1992706402
Provider Name (Legal Business Name): ALLAN SCOTT DETWEILER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/17/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 DOUGHTY BLVD
INWOOD NY
11096-2135
US

IV. Provider business mailing address

271 DOUGHTY BLVD
INWOOD NY
11096-2135
US

V. Phone/Fax

Practice location:
  • Phone: 516-371-6884
  • Fax: 516-371-6083
Mailing address:
  • Phone: 516-371-6884
  • Fax: 516-371-6083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number205232
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS0007505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: