Elizabeth A Detlie, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

27679 Issued in MN

Practice address

404 Highway 96 W
Shoreview, MN 55126-1900

Phone

(651) 483-8283

Fax

(651) 483-8299

NPI assigned

Aug 1, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154390400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1318550400000",
    "number": "1114933744",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2025 SLOAN PL",
            "address_2": "STE 35",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551172007",
            "telephone_number": "651-772-1572",
            "fax_number": "651-772-1889"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "404 HIGHWAY 96 W",
            "city": "SHOREVIEW",
            "state": "MN",
            "postal_code": "551261900",
            "telephone_number": "651-483-8283",
            "fax_number": "651-483-8299"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DETLIE",
        "first_name": "ELIZABETH",
        "middle_name": "A",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-01",
        "last_updated": "2011-10-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "27679",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "129886100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sydney Christine Daley, RD, CSSD
• Temitope Abiola Dawodu, DNP, FNP, PMHNP- BC
• Taylor Degen
• Debbie Lynn Deloye
• Edward Martel Dennison, MD
• Liban Dima
• Larissa M Dimitrov, MD
• Kimberly A Donahue, PT, DPT
• Tacy Donnelly
• Sarah Newberry Donovan, LPCC, MT-BC

• All providers in Shoreview, MN
• Family Medicine Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.