=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881278992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW ROBERT DETTER MD, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2021
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 WOODRUFF CIRCLE WMB 1105
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30322-4238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-712-1504
-----------------------------------------------------
Fax | 404-544-1569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1173 WILLIVEE DR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-4122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-409-3318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 97628
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------