Provider Demographics
NPI:1063488534
Name:DEPRET-GUILLAUME, SERGE E (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGE
Middle Name:E
Last Name:DEPRET-GUILLAUME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 HEALTH PARK DR FL HP2
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4692
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:4910 VALLEY VIEW BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-2040
Practice Address - Country:US
Practice Address - Phone:540-265-4210
Practice Address - Fax:540-265-4219
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063488534Medicaid
VA00X967C03Medicare PIN
VAP00696500Medicare PIN
VAF36388Medicare UPIN