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General NPI Number Information
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NPI Number | 1649404195
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Entity Type | Individual
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Provider Name | JAVIETH H DETRES MD
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Gender | Male
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Dates
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Enumeration Date | 05/13/2009
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Last Update Date | 02/19/2025
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Provider Practice Location Address
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Address Line | 4850 W OAKLAND PARK BLVD STE 136
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City | LAUDERDALE LAKES
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State | FL
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Zip | 33313-7277
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Country | US
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Telephone | 844-665-4827
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Fax | 877-762-0841
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Provider Business Mailing Address
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Address Line | 9150 MERIDIAN DR E
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City | PARKLAND
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State | FL
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Zip | 33076-4612
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Country | US
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Telephone | 787-240-4646
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 140765
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License Number State | FL
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