Provider Demographics
NPI:1497902589
Name:DERUE, KATHERINE WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:WILSON
Last Name:DERUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:ELIZABETH
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR
Mailing Address - Street 2:PO BOX 0446 LOBBY J
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:STE 3111
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-712-7688
Practice Address - Fax:734-712-7056
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096026208000000X, 2080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics