Provider Demographics
NPI:1265429203
Name:DERUELLE, DENNIS P (MD, FHM)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:P
Last Name:DERUELLE
Suffix:
Gender:M
Credentials:MD, FHM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6616 ELLWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-3929
Mailing Address - Country:US
Mailing Address - Phone:813-966-1077
Mailing Address - Fax:
Practice Address - Street 1:1270 NORTHLAND DR STE 250
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1156
Practice Address - Country:US
Practice Address - Phone:813-966-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073520207R00000X
TN60938207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253098800Medicaid
FL41576OtherBC FLORIDA
FL41576AMedicare ID - Type Unspecified
FL41576XMedicare PIN
G04526Medicare UPIN
FL253098800Medicaid