Provider Demographics
NPI:1083716070
Name:DERUYTER, REBECCA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ANN
Last Name:DERUYTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 HOLTON DR
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2884
Mailing Address - Country:US
Mailing Address - Phone:712-546-6868
Mailing Address - Fax:712-546-6739
Practice Address - Street 1:1111 HOLTON DR
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-2884
Practice Address - Country:US
Practice Address - Phone:712-546-6868
Practice Address - Fax:712-546-6739
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAU96064Medicare UPIN
IAI10177Medicare ID - Type Unspecified