Individual
DR. WILLIAM RUSSELL DETTEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1530 E REPUBLIC RD, SPRINGFIELD, MO 65804-6530
(417) 269-1362
(417) 269-1372
Mailing address
PO BOX 4046, SPRINGFIELD, MO 65808-4046
(417) 269-1362
(417) 269-1372
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
R4P90
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
246778419
—
MO
01
—
5716
BLUE CROSS MO
—
Enumeration date
08/30/2006
Last updated
11/12/2012
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