Provider Demographics
NPI:1093777658
Name:DERUITER, SCOTT ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:DERUITER
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:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-2200
Mailing Address - Fax:719-553-2216
Practice Address - Street 1:109 S BURLINGTON DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81007-5560
Practice Address - Country:US
Practice Address - Phone:719-553-2205
Practice Address - Fax:833-314-0183
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43016207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59626569Medicaid
CO59626569Medicaid
CO811553Medicare PIN
CO801893Medicare PIN