Healthcare Provider Details

I. General information

NPI: 1740818046
Provider Name (Legal Business Name): ANDREW STEPHEN DETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 E TOWN ST
COLUMBUS OH
43215-4602
US

IV. Provider business mailing address

290 E TOWN ST
COLUMBUS OH
43215-4602
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-9108
  • Fax: 614-566-9110
Mailing address:
  • Phone: 614-788-5400
  • Fax: 614-788-5500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.148283
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: