Provider Demographics
NPI:1518205715
Name:CLEARWATER GASTROENTEROLOGY
Entity type:Organization
Organization Name:CLEARWATER GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:DETTWILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-743-4373
Mailing Address - Street 1:2517 17TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6311
Mailing Address - Country:US
Mailing Address - Phone:208-743-4373
Mailing Address - Fax:
Practice Address - Street 1:2517 17TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6311
Practice Address - Country:US
Practice Address - Phone:208-743-4373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty