Provider Demographics
NPI:1134196280
Name:DERUYTER, DAVID N (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:N
Last Name:DERUYTER
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 1:3193 HOWELL MILL RD NW
Mailing Address - Street 2:SUITE 322
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327
Mailing Address - Country:US
Mailing Address - Phone:404-352-3683
Mailing Address - Fax:404-351-8144
Practice Address - Street 1:3193 HOWELL MILL RD NW
Practice Address - Street 2:SUITE 322
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327
Practice Address - Country:US
Practice Address - Phone:404-352-3683
Practice Address - Fax:404-351-8144
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0035239207RP1001X
GA035239207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00506316AMedicaid
GA39BDBQCMedicare PIN
GA00506316AMedicaid