Provider Demographics
NPI:1689656720
Name:DIPRETA, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:DIPRETA
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 1:3008 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4241
Mailing Address - Country:US
Mailing Address - Phone:912-265-2142
Mailing Address - Fax:912-265-0530
Practice Address - Street 1:3008 E PARK AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4241
Practice Address - Country:US
Practice Address - Phone:912-265-2142
Practice Address - Fax:912-265-0530
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052707207N00000X, 207NI0002X, 207NS0135X, 207ND0900X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA487177354Medicaid
GADC4061OtherRAILROAD MEDICARE
GAP00182483OtherRAILROAD MEDICARE
GA52046337014OtherBCBS (BWKDERM)
GA52046337012OtherBCBS (GA DERM)
07BBSPZMedicare ID - Type Unspecified
GA487177354Medicaid