Healthcare Provider Details

I. General information

NPI: 1548259617
Provider Name (Legal Business Name): SAMUEL T DETWILER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 MEMORIAL AVE STE 10
LYNCHBURG VA
24501-2652
US

IV. Provider business mailing address

7126 FAIRWAY DR
BUTLER PA
16001-8596
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-5200
  • Fax: 434-200-5200
Mailing address:
  • Phone: 724-256-6960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-00-7985
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS016525
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102209331
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: