Provider Demographics
NPI:1659378412
Name:DERRER, DAVID T (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:DERRER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:805 SANDY PLAINS ROAD
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4550 COBB PARKWAY NORTH NW STE 101
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:470-956-0100
Practice Address - Fax:770-529-0279
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA054181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA054181OtherGEORGIA MEDICAL LICENSE #
GA015928OtherBLUE CROSS/BLUE SHIELD #
BD6857467OtherDEA REGISTRATION NUMBER
GA054181OtherGEORGIA MEDICAL LICENSE #
H58783Medicare UPIN
GA111838Medicare Oscar/Certification