Provider Demographics
NPI:1679810394
Name:DETRICH, ROBERT ELIOT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ELIOT
Last Name:DETRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 HOOVER ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-4231
Mailing Address - Country:US
Mailing Address - Phone:760-672-2687
Mailing Address - Fax:
Practice Address - Street 1:1230 HOOVER ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-4231
Practice Address - Country:US
Practice Address - Phone:760-672-2687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGFE 19292207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology