Provider Demographics
NPI:1255353660
Name:HAUTER, DRU D (MD)
Entity type:Individual
Prefix:DR
First Name:DRU
Middle Name:D
Last Name:HAUTER
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 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3649
Practice Address - Street 1:1437 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2085
Practice Address - Country:US
Practice Address - Phone:309-454-4411
Practice Address - Fax:309-451-6951
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5715395OtherBLUE CROSS BLUE SHIELD
IL748940Medicare ID - Type UnspecifiedMEDICARE GROUP
E91837Medicare UPIN
5715395OtherBLUE CROSS BLUE SHIELD